Multi-Commodity Education Program
Enrollment Form Instructions
1. This document is formatted as a Microsoft Word Form. To enter your responses,
click your mouse in the gray area and begin typing.
2. Navigate to different areas in the form by using your mouse or the tab key. Clicking
in a gray area will cause it to darken, which means you can begin typing.
3. Do not use the enter key to change fields. Use only the tab key or mouse.
4. When finished, please e-mail or fax your form to:
Debra Holderfield – dholderfield@cotton.org
National Cotton Council
901-725-0510 – fax
901-274-9030 – office
5. A digital photograph of each participant is requested but not required.
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Multi-Commodity Education Program
Enrollment Form
Personal Information
1. Your name as listed on driver’s license:
2. I prefer to be called:
3. Date of birth:
4. Spouse name:
5. Please provide two emergency contacts:
Name
Relationship
Phone Numbers
- home
- office
- mobile
- home
- office
- mobile
6. Mailing Address:
7. E-mail address:
8. Mobile phone:
9. Office phone:
10. Home phone:
11. Fax:
Travel Preferences
1. Airport preferences:
Airport (in order of preference)
Distance from Home
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2. Seat preference:
Window
Middle
Isle
No preference
3. Hotel room preferences:
Smoking preference:
Non-Smoking
Smoking
No preference
Room type:
King bed
Double bed
No preference
4. List any food allergies and special meal requirements:
Describe Your Farming Operation (include crops & approximate acreages)
Summarize Other Business Interests
Association Memberships
Summarize Any Leadership Positions Held in Above
Please e-mail or fax your completed enrollment form to Debra Holderfield:
dholderfield@cotton.org
901-725-0510 – fax
901-274-9030 - office
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