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AM/PIC Registration
2024 GACAA AM/PIC Registration
Georgia Association of County Agriculture Agents
PLEASE PRINT THIS FORM BEFORE YOU HIT SUBMIT SO YOU HAVE A COPY.
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP
Office Phone
(Required)
Cell Phone
Agent Information
County/State Staff/Specialist
(Required)
Enter your county name, state staff, or specialist
District/State Staff
(Required)
Enter Northwest, Northeast, Southwest, Southeast or State Staff
Meals needed:
(Required)
Monday November 11 - Social & meal
Monday November 11 - New members meet & greet
Tuesday November 12 - Breakfast
Tuesday November 12 - Lunch
Tuesday November 12 - Annual Banquet
Wednesday November 13 - Breakfast
Select All
These meals are included in your conference registration. Please select all that you will be attending.
Vegetarian meals?
Yes
No
There is a box below if there are other dietary restrictions that we need to know.
Activities/Tours
(Required)
Monday November 11 - Golf
Monday November 11 - Skeet shooting
Monday November 11 - Horse ride on the bead
Monday, November 11 - Bike rental
Monday, November 11 - Mini-golf / summer waves
Monday, November 11 - Paint & Sip
Tuesday November 12 - Tour 1: Gilliard Farms
Tuesday November 12 - Tour 2: Sea turtle center (limit of 30 people)
Tuesday November 12 - Tour 3: Marine Ext.
Tuesday November 12 - Tour 4: Jekyll 4H Center
None
Please select all that you plan to attend. Some tours have a limit so will be first come first added.
Conference Cost
(Required)
Pay by Card ($165+$5 Convenience Fee)
Pay by Check ($165)
Tuesday only/Banquet By Card ($60+$5 Convenience Fee)
Tuesday only/Banquet ($60)
A $5 convenience fee is included for paying by credit card.
Final Price
If you are paying by check please print and mail with your payment to: Guy Hancock, GACAA Treasurer, 4602 Research Way, 305 HH Tift Bldg. Tifton, GA 31793-5766
Credit Card
Cardholder Name
Card Details
Any other special needs or requirements (dietary, mobility, physical)? Please indicate in box below.
Comments
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