Referee Registration Form - U.s. Soccer Federation
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1U.S. SOCCER FEDERATION
(Check Only ONE)
20
REFEREE REGISTRATION FORM
Referee
Assignor
Beach
Instructor
Indoor
Year
Assessor
Futsal
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
Secondary E-Mail
Primary Phone
Gender
Date of Birth
-
-
-
MO
DAY
YEAR
Current USSF Referee Grade Level
Date Attained Present Grade
Current State Affiliation
District
-
-
MO
DAY
YEAR
STEP 2: Upgrade Request
STEP 4: Information Certification
(This section must be completed)
I request an upgrade from my current grade.
I understand that by successfully completing the educational requirements and registering with the
STEP 3: Affiliated Game Experience For Prior Year
USSF, Inc. as a referee, I am entitled to act as a game official at the appropriate level of competition
(Re-certifying referees and assessors only)
indicated by my approved grade. I understand that my registration does not guarantee my receipt of
Enter actual game count
any specific refereeing assignments and does not apply to non-USSF affilliated games. I further
understand that my registration with USSF does not create an employment contract or an
ASSIST.
LEVEL OF GAME
REFEREE
employment relationship with USSF.
REFEREE
Have you ever been convicted of a felony, a crime of violence, any crime against an individual, or
International FIFA Appointments
(REJECTED IF LEFT BLANK)
fraud?
Yes
No
Professional Game
Other International Appointments
I also certify that I have no physical illness or impairment which will make participation in
soccer-related activities dangerous to me.
Top National Games
I agree to participate in, and comply with, the risk management program of the Federation and/or
Regional Leagues
Organization Member through which I am participating.
Registrant represents that the information contained in this form is true and correct, and that Registrant
Top Amateur/Division I Games
has not lied about, misrepresented or otherwise falsified such information. Incomplete forms will be
returned.
Other Amateur Games
-
-
Youth (U-19) Games
Signature
Youth (U-16 and below) Games
Rejected if not signed
MO
DAY
YEAR
Date signed
Other Games (Specify)
OFFICE USE ONLY:
GRADES
Emeritus
OFFICE USE ONLY
CERTIFICATION/UPGRADE INFORMATION
1 - 2
International
13 National
(Fill-in or circle as appropriate)
3 - 4
National
14
Cash
5
6
State
15 State
Paid by:
Amount Paid:
Referee
7
8
16
Check (No.)
Initial
Recreational
9
11
12
Written Test:
ADMINISTRATIVE CERTIFICATION OF COMPLETION
Date
Score
Initial
(REJECTED IF LEFT BLANK)
Field Test:
Pass
Fail
Name
Title
Date
Initial
UPGRADE GAME EXPERIENCE
Date
Assessor
Score
Initials
State Association
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
DO NOT MAIL TO FEDERATION HEADQUARTERS
9360573519
Revised 7/2013
White - State copy
Yellow - Referee copy
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