NAME

ADDRESS

CITY

COUNTY

STATE Zip

Phone - -

E-Mail

Check Occupation (check all that apply)

Grower

PCA

Packer

Vintner/Processor

Research/Gov/Ed

Assn/Commission

Supplier/Mfg/Svc

Ad Agency

Other

List Acreage Totals - (all fields must be filled in. Use a zero where you have no acreage)
Table Grape Acres

Raisin Acres

Wine/Juice Grape Acres

Please Answer Personal Question below for verification Purposes

What High School did you graduate from?