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Name

Address

Phone

Have you ever been convicted of a crime other than a traffic violation?

Yes No

If “Yes,” please state the nature of offense, date, place and court name/address (conviction will not necessarily bar applicant from officiating)

Official/Player Experience – List below all present and past experience beginning with your most recent

What sport(s) are you interested in officiating this season?

Boys Tackle Football Girls Flag Football Both

Do you have any conditions that could be affected by officiating?

Yes No

If “Yes,” please briefly describe