Free Regis. Form

The pre-registration deadline is Friday, June 9, 2012, because we need a head-count to order the right amount of beverages and food.

To submit your free registration form, please complete ALL the information requested below, and then click the Submit Form button at the bottom of this page.

To qualify for a free registration, you must be an employee or member of any federal, state,

or local government agency or entity, a Master Well Owner, or a teacher or student.

Commission and authority members and employees also qualify for free registration.

Please provide the following contact information to qualify for a free registration:

Name:

Title:

Organization:

Work Phone:

E-mail:

     PG's & PE's: Check this box if you are a licensed PG or PE and you want to receive an Attendance Certificate for 6.6 PDH's. Your name will appear on the certificate just as you have entered it above on line 1.

Note: We need your e-mail address so we can send a registration confirmation to you.

We will not release your e-mail address. If you do not have e-mail, please place your fax number in the e-mail field.

Please tell us how you heard about the 2012 PGWA Summer Field Conference by clicking a button below:

E-Mail from within my agency or organization

A colleague or co-worker told me

The Pennsylvania Driller Newsletter

My State Association's Newsletter

This PGWA Web site

Clicking the Submit Form button will display the data you have entered above, and will send this Free Registration Form to Rose Ann Hoover of the Pennsylvania Ground Water Association. If you need to contact Rose Ann Hoover by e-mail click this link, or call her at (814) 933-8714.