2023 AgMazing Congressional Tour Registration Form

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Sponsored by the St. Louis AgriBusiness Club

First Name for Nametags *

First Full Name for Airline Ticket *

Last Name *

Middle Name *

Gender *

Male

Female

Birthdate *

(Month/Day/Year) 00/00/2000

State Representing *

Office Representing *

First Name and Last Name of Senator or Representative with District # *

Enter None if not applicable

Name of Agency or Affiliation Representing *

Enter None if not applicable

Email Address *

Cell Phone Number *

(xxx) xxx-xxxx

Office Phone Number *

(xxx) xxx-xxxx

Wednesday, August 23 *

Attending - 1 Not Attending - 0

Thursday, August 24 *

Attending - 1 Not Attending - 0

Friday, August 25 *

Attending - 1 Not Attending - 0

Preferred hotel room *

Single

Double

None

Flight Needed DC to STL? *

August 23 - Southwest - 8:35(ET) AM leaves Washington DC Reagan National (DCA) - 9:45(CT) AM arrives St. Louis - NONSTOP If this time does not work, please suggest other Southwest flight time and day. Yes - 1 No - 0

Other:

Required

Flight Needed STL to DC? *

August 25 - Southwest - 3:55(CT) PM leaves St. Louis - 6:50(ET) PM arrives Washington DC - NONSTOP. If this time does not work, please suggest other Southwest flight time and day. Yes - 1 No - 0

Other:

Required

Driving *

If Yes, indicate your arrival and departure time and day.

Yes

Other:

Required

TSA Precheck

Frequent Flyer Number Southwest *

Enter none if not applicable

Dietary Needs

Brief Bio *

Staff photos and bio will be provided to all participants prior to the trip.

Question

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