21st Annual Pesticide Stewardship Virtual Conference – February 2-4, 2021 Please fill out the registration form below. If you have any issues or questions with this form, please contact us. Step 1. Contact InformationName* First Last OrganizationEmail* Enter Email Confirm Email Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Step 2. Conference Registration$50 Individual TPSA Member until 1/25/2021 (after: $100.00 for individual TPSA members) Price: $50.00 Quantity: $100 Organizational TPSA Member until 1/25/2021 (after $200.00 for Organizational TPSA Member) Price: $100.00 Quantity: $75 Non-Member Individual until 1/25/2021 (after $150.00 for Non-Member Individual) Price: $75.00 Quantity: TOTAL $0.00 Enter payment at the end of this form.Step 3. Membership(IF YOU HAVE NOT RENEWED YOUR MEMBERSHIP) - The Pesticide Stewardship Alliance - 2021 Membership Form - September 1, 2021 - August 31, 2021 (not a part of Conference Registration)Individual – $75 (Membership is free to Sponsors contributing $1,500-$5,499.) Price: $75.00 Quantity: Provide full name, address, phone number and email below.Organization – $200 (Membership is free to 3 members per organization in an organizational membership. Also, free to Gold Sponsors contributing $5,500 or more) Price: $200.00 Quantity: Provide full name, address, phone number and email below.TOTAL $0.00 Step 4. Affiliation of MembershipEach member please select one of the following areas of affiliation that represents your primary personal/professional area of focus within TPSA.Choosing one affiliation per member does NOT prohibit any TPSA member from being actively involved in any TPSA committee, group, meeting, or voting. Affiliation records serve to assist with Conference planning, Membership assessment, BOD nominations, and overall Organization focus. UNITED STATES ENVIRONMENTAL PROTECTION AGENCY (U.S. EPA) Individuals employed by the U.S. EPA. GOVERNMENT AGENCY Individuals employed by a local, state or federal agency (except the U.S. EPA). PESTICIDE INDUSTRY Entities or organizations that manufacture, formulate or distribute pesticides; manufacture or distribute pesticide containers; conduct pesticide research, education, training or consultation; manufacture, sell or distribute equipment and/or other products that are utilized in any aspect of pesticide manufacture, commerce, packaging, transport, application, use, and storage; and pesticide industry sponsored and funded organizations that undertake pesticide stewardship activities. WASTE MANAGEMENT INDUSTRY Entities or organizations that identify, package, or transport waste pesticides and residues, recycle waste pesticides and residues and/or pesticide equipment or containers or manufacture equipment to accomplish any of the above; and any waste-management industry sponsored and funded organizations that undertake pesticide stewardship activities. PESTICIDE CONTAINER MANAGEMENT INDUSTRY Organizations that are involved in any aspect of pesticide container management and any pesticide container management industry sponsored and funded organizations that are involved with pesticide stewardship activities. INSTITUTIONS Entities that are involved with research, teaching or extension in an area or areas of pesticide stewardship. END USERS Individuals or businesses that use or apply pesticides and organizations, trade associations or commodity groups that represent end-users or applicators. PUBLIC OR ENVIRONMENTAL HEALTH Individuals and organizations that are involved with environmental and natural resource protection, recycling, pollution prevention or other conservation or ecological issues and any other corporations that do not fit into any other category. NON-AFFILIATED Individuals and organizations that do not wish to identify with or do not fit into an area of affiliation listed above. Step 5. Sponsor Information - Please contact the TPSA office for more info. (314) 849-9137Step 6. PaymentPayment - pay with credit card or if paying by check, make payment to TPSA with a copy of the registration form and mail to TPSA, 11327 Gravois Road, Suite 201, St. Louis, MO 63126. To pay with credit cards, click below. You do not need to have a PayPal account to use this function. If paying by PayPal and paying for someone besides yourself – please include their name(s) to ensure payment is applied to proper person. * Payable in US dollars. * By paying for conference, attendee gives permission to be contacted by TPSA via email.GRAND TOTAL $0.00 *** Pay for your registration securely by clicking the PayPal button below. You can use the PayPal Guest Checkout to pay with any major credit card. A PayPal account is not required. ***