U.s Soccer Federation Referee Registration Form

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U.S. SOCCER FEDERATION
(Check Only ONE)
REFEREE REGISTRATION FORM
20
Referee
Assignor
Instructor
Indoor/Futsal
Year
Assessor
LETTERS
STOP: BEGIN HERE - COMPLETE STEPS 1 - 5 USING ONLY BALLPOINT PEN AND CAPITAL
STEP 1: Biographical Information
USSF ID No. (Required for re-certifying referees)
-
-
-
MI
Last Name
First Name
Address
City
State
Zip Code
-
E-Mail Address
@
Home Phone
Work Phone
Gender
Date of Birth
-
-
-
-
Country of Birth (e.g. USA)
Country of Citizenship (e.g. USA)
MO
DAY
YEAR
Current USSF Referee Grade Level
Date Attained Present Grade
Current State Affiliation
District
-
-
MO
DAY
YEAR
STEP 2: Upgrade Request (Complete only if upgrade requested)
STEP 4: Donations - (Please check box and enter dollar amound)
I request an upgrade from my current grade.
Donation for the National Training Center $
Donation for the National Soccer Hall of Fame $
STEP 3: Affiliated Game Experience For Prior Year
(Re-certifying referees and assessors only)
STEP 5: Information Certification
(This section must be completed)
Enter actual game count
ASSIST.
I understand that by successfully completing the educational requirements and registering with the
LEVEL OF GAME
REFEREE
USSF, Inc. as a referee, I am entitled to act as a game official at the appropriate level of competition
REFEREE
indicated by my approved grade. I understand that my registration does not guarantee my receipt of
any specific refereeing assignments and does not apply to non-USSF affilliated games. I further
International FIFA Appointments
understand that my registration with USSF does not create an employment contract or an
employment relationship with USSF.
Professional Game
Have you ever been convicted of a felony, a crime of violence, any crime against an individual, or
Other International Appointments
(REJECTED IF LEFT BLANK)
fraud?
Yes
No
Top National Games
If answer is yes, please read the directions on the instruction sheet.
I also certify that I have no physical illness or impairment which will make participation in
Regional Leagues
soccer-related activities dangerous to me.
I agree to participate in, and comply with, the risk management program of the Organization member
Top Amateur/Division I Games
through which I am participating.
Other Amateur Games
Registrant represents that the information contained in the form shall be true and correct, and that
Registrant has not lied about, misrepresented or otherwise falsified such information. Incomplete
Youth (U-19) Games
forms will be returned.
-
-
Youth (U-16 and below) Games
Signature
Rejected if not signed
MO
DAY
YEAR
Other Games (Specify)
Date signed
OFFICE USE ONLY
OFFICE USE ONLY:
GRADES
Emeritus
CERTIFICATION/UPGRADE INFORMATION
1 - 2
(Fill-in or circle as appropriate)
International
13 National
Cash
3 - 4
Paid by:
National
14
Amount Paid:
Check (No.)
5
6
State
15 State
Initial
Referee
7
8
16
National Training Center Donation Amount:
Recreational
9
11
12
Written Test:
ADMINISTRATIVE CERTIFICATION OF COMPLETION
Date
Score
Initial
Field Test:
Pass
Fail
Name
Title
Date
Initial
UPGRADE GAME EXPERIENCE
State Association
Date
Assessor
Score
Initials
Signature
Date
Assessor
Score
Initials
-
-
Date upgrade requirements met
(Check only one box)
Date
Assessor
Score
Initials
MO
DAY
YEAR
New
Recert.
Upgrade
Downgrade
Transfer
AYSO
Revised 6/2008
DO NOT MAIL TO FEDERATION HEADQUARTERS
9360573519
White - State copy
Yellow - Referee copy

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