Virtual Roundtable Registration Form

OSM 2022 Pump Rodeo Application
Application Requirements
- Limited to ACPA Certified Operators
- Operator to provide a photo ID at onsite registration
- Applicant and member company agree to photos and promotional use of applicant name, company name and photos
Competition is limited to 20 qualified participants
Operator Name *

First Name Last Name
Company Name *
E-mail *
example@example.com
Phone *
Mobile Phone *
Used for important event updates leading up to the event and onsite.
Operator Number *
Last 4 Digits of SSN
Please list any dietary restrictions
ie. Vegetarian, Vegan, Gluten-Free, Nut allergy, etc.
Emergency Contact Person *

First Name Last Name
Emergency Contact Phone Number *
This number will only be used should an emergency occur while you are onsite for the event.
Remote Preference

HBC Z-Boom
Boom Preference

Scanreco Roll
Pump Rodeo Fee & Guest Add-Ons
prev next ( X )
Pump Rodeo Participant Fee includes lunch & Saturday night awards dinner
$ 100.00

Pump Rodeo Guest 12 yrs + Guest of Pump Rodeo participant. Additional Fee includes lunch & Saturday night awards dinner for this guest.
$ 50.00 Quantity

Pump Rodeo Guest 5-11 yrs. Guest of Pump Rodeo participant. Additional Fee includes lunch & Saturday night awards dinner for this guest.
$ 30.00 Quantity

Pump Rodeo Guest Under 5 yrs. Guest of Pump Rodeo participant. Additional Fee includes lunch & Saturday night awards dinner for this guest.
Free Quantity

Total

$ 0.00
Please list the full names of your guest(s):

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

OSM 2022 Pump Rodeo Application

Application Requirements