IABA REFEREE / JUDGE APPLICATION FORM

IABA REFEREE / JUDGE APPLICATION FORM

PLEASE COMPLETE ALL FIELDS IN BLOCK CAPITALS

 

CLUB NAME:                      ________________________________________

 

COURSE NAME:                 REFEREE / JUDGE COURSE_____________

 

 

FIRST NAME:                     ________________________________________   

 

 

SURNAME:                          ________________________________________   

 

 

DATE OF BIRTH:               ________________________________________   

 

 

ADDRESS:                            ________________________________________   

 

                                                ________________________________________   

 

                                                ________________________________________   

 

                                                ________________________________________   

 

 

PHONE NO:                          ________________________________________   

 

 

 

 

TO BE FILLED OUT BY CLUB SECRETARY

 

I hereby confirm that the above applicant is a member of____________________________ Boxing Club, has applied to be fully vetted by An Garda Síochána/Access NI, and is eligible to attend a REFEREE / JUDGE Course.

 

SIGNED:                    _________________________________

 

PRINT NAME:          __________________________________

 

DATE:                        __________________________________

 

 

Please send the completed form to your COUNTY BOARD SECRETARY

 

 

 

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