Transfer/clearance Request

Please Tick

Mainland Football

P O Box 21122

Within Federation 6

Edgeware

Inter Federation (from – 1 2 3 4 5 7 )

Christchurch

International (Country _______________ )

Phone: (03) 355 3595

Fax:

(03) 355 4976

TRANSFER/CLEARANCE REQUEST

If club to club transfer is within Mainland this form must be completed in full, it is the responsibility of the

player named or their new club to go to the Secretary of the old club to have this form completed and signed.

If Inter Federation or International clearance is required, player and new club fill in their respective parts only.

On completion fax or forward to Mainland Football. Forms that are not fully completed may not be processed.

____________________________________________________________________________________________________________________________________________________________________________

Player to complete

PLEASE PRINT CLEARLY

Player’s Full Name:

_______________________________________________________ M / F

(LAST NAME)

(FIRST NAME)

Date of Birth:

_______/_________/________ Phone:

_____________________

(

/

/

)

(

)

DD

MM

YYYY

HOME

______________________________________ Phone:

_____________________

Address:

(

)

BUS

______________________________________ Phone:

_____________________

(

)

MOB

: _________________________ Email: _________________________________________

Country of Birth

I wish to be cleared to play for the

____________________________ Club for the 20_____ Season.

(New Club)

I declare that I last played for the

____________________________ Club ________________City.

(Old Club)

I consent to the collection of this information by the Club and Mainland Football for the purpose of a membership record and for them to retain, use and

disclose the information as appropriate to NZ Football, SPARC, Funding agencies and Sponsors. I acknowledge my right to access and correct this

information. This consent is given in accordance with The Privacy Act 1993.

Player’s Signature:

_________________________________________________

______________________________________________________________________________________

New Club to Complete

PLEASE PRINT CLEARLY

New Club’s Name

_________________________________________________

Is this player a Guest Player?

Yes / No

(See NZ Football Reg 5.8 – applies to non-NZ citizens or non-permanent residents)

Signed_________________________________

Date:

________/__________/_________

(Authorised Club Signatory)

______________________________________________________________________________________

Old Club or Federation to Complete

PLEASE PRINT CLEARLY

Approved

/

Declined

Clearance circle one:

If declined, please state reasons:

______________________________________________________________________________________

______________________________________________________________________________________

Current No. of Yellow Cards: ____________________

Suspension to serve:

_______________

Signed_________________________________

Date:

________/__________/_________

(Authorised Club or Federation Signatory)

WHEN COMPLETED, PLEASE FAX BACK TO MAINLAND FOOTBALL (03) 355 4976

MAINLAND FOOTBALL USE ONLY

Date Clearance requested:

____________________

Date reply received:

_______________

ID number:

____________________

New Club informed:

_______________

Entered in Database:

____________________

Signed on behalf of Mainland Football

_____________________________________________________

No: 6 District Federation of New Zealand Football Incorporated;

Phone: +64-3-355 3595 Fax:+64-3-355 4976

English Park, 127 Cranford Street, P O Box 21122, Edgeware, Christchurch, New Zealand.

C:\Group documents\Forms\Transfer Clearance Request New.doc