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70th PIAW Annual Convention
  1. You are registering for the following Event:

    70th PIAW Annual Convention
    August 7-8, 2019
    Wisconsin Dells, WI

    Online registration is only available with credit card payment. Pre-payment is required. Registration without payment will not be processed.
    PIAW now accepts the following major credit cards:
    mastercard 48visa 48amex 48discover 48
    Payments are securely processed through Payment Service Network.
  1. Please enter your information below.
  2. First Name(*Required)
    Please tell us your first name.
  3. Last Name(*Required)
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  4. Designations
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  5. First Name Preference
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  6. WI NPN #
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  1. Business Name
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  2. Address(*Required)
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  3. City(*Required)
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  4. State(*Required)
    Please tell us your state.
  5. Zip Code(*Required)
    Please enter a valid zip code.
  6. Phone(*Required)
    Please enter a valid phone number
    xxx-xxx-xxxx
  7. Cell Phone
    Please enter a valid phone number
    xxx-xxx-xxxx
  8. Email(*Required)
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  1. Your Registration Status(*Required)
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  2. Please select your registration option (Please call PIAW if you need to determine your membership status.)(*Required)
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  3. Please select if attending
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  4. Please select if attending

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  5. Please select if attending
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  6. Please make your Ala Carte Selections below.
  7. Wednesday Options
  8. Please select if you wish to attend:
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  9. Please select if you wish to attend the Opening Party:
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  10. Thursday Options
  11. Please select if you wish to attend:

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  15. Would you like to register a Spouse or a Guest?
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  16. NOTE - THIS IS FOR NON INDUSTRY GUESTS ONLY – Please complete a separate registration for each agent or insurance industry registrant.
  17.                          Please enter the information for your 1st Guest/Spouse below.                         

  18. Full Name(*Required)
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  19. First Name Preference
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  20. City(*Required)
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  21. State
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  22. Child Age
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  23. Your Spouse/Guest Registration Status(*Required)
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  24. Please select your guest/spouse registration option. (Please call PIAW if you need to determine your membership status.)(*Required)
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  25. Please make your Guest/Spouse Ala Carte Selections below.
  26. Please select all of your guest/spouse Wednesday Option(s)
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  27. Please select all of your guest/spouse Thursday options
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    Use the SHIFT key while clicking to make multiple selections


  28. Would you like to register another Guest?
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  29. NOTE - THIS IS FOR NON INDUSTRY GUESTS ONLY – Please complete a separate registration for each agent or insurance industry registrant.
  30.                              Please enter the information for your 2nd Guest below.                             

  31. Full Name(*Required)
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  32. First Name Preference
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  33. City(*Required)
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  34. State
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  35. Child Age
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  36. Your Guest Registration Status(*Required)
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  37. Please select your guest/spouse registration option. Please select your guest/spouse registration option. (Please call PIAW if you need to determine your membership status.)(*Required)
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  38. Please make your Guest/Spouse Ala Carte Selections below.
  39. Please select all of your guest/spouse Wednesday Option(s)
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  40. Please select all of your guest/spouse Thursday options
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    Use the SHIFT key while clicking to make multiple selections


  41. Would you like to register another Guest?
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  42. NOTE - THIS IS FOR NON INDUSTRY GUESTS ONLY – Please complete a separate registration for each agent or insurance industry registrant.
  43.                              Please enter the information for your 3rd Guest below.                             

  44. Full Name(*Required)
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  45. First Name Preference
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  46. City(*Required)
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  47. State
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  48. Child Age
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  49. Your Guest Registration Status(*Required)
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  50. Please select your guest/spouse registration option. Please select your guest/spouse registration option. (Please call PIAW if you need to determine your membership status.)(*Required)
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  51. Please make your Guest/Spouse Ala Carte Selections below.
  52. Please select all of your guest/spouse Wednesday Option(s)
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  53. Please select all of your guest/spouse Thursday options
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    Use the SHIFT key while clicking to make multiple selections
  54. Amount Due
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  1. By clicking here, you understand and agree to our terms and conditions.

    Please check to verify that you have read and agree to the terms listed.
  2. Event
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  1. Please enter your payment information below.

    PIAW now accepts the following major credit cards:
    mastercard 48visa 48amex 48discover 48
    Payments are securely processed through Payment Service Network.
  2. Credit Card Number(*Required)
    Please enter a valid Credit Card Number
  3. Credit Card Expiration(*Required)
    Please enter your Expiration date as MMYY
    MUST BE IN THE FORMAT MMYY (no spaces or / )
  4. CC Billing Address Zip Code(*Required)
    Please enter a valid zip code.
  5. WARNING: Clicking "submit" more than once may result in multiple charges to your credit card.
    Your confirmation will be emailed within 24 hours.

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Professional Insurance Agents of Wisconsin
6401 Odana Road | Madison, WI 53719
Phone: (608) 274-8188 | Toll Free (800) 261-7429
Fax: (608) 274-8195 | Toll Free (866) 203-7461

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