Yes: No: Yes: No

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Futhermore, I understand that the Board of Directors can use my driver's license number and social security number to perform an NCIC background check.


First Name:

Last Name:

Address: Home Phone: __

City: __-__ __-_

Email Address: ______

___ Work Phone: __

State: __-__

Zip Code: __-_

__________________ Occupation: _____

Affiliated Game Experience: Please check all that apply Level Position □Flag Football □Youth Football □Jr. High / Middle School □Junior Varsity HS □Varsity HS □Minor League □Collegiate

___ Cell: __

__-__ __-_



Years Experience

Have you ever had your membership with any other officials association canceled, suspended or revoked? Yes: □ No: □ Please list any team that you may have an affiliation with, including any relative, co-worker or child that may coach, play or have an interest in any team participating in the SYFA where a conflict of interest may arise. If so, which team? __________________ _ Division: _ ______ Did you officiate at SYFA last year? Yes: □ No: □ Are you certified? Yes: □ No: □ If yes, is your membership current? Yes: □ No: □ Date of Issue: _____________ Exp Date: _____________ Are you currently under indictment? Yes: □ No: □ Have you ever been convicted of a felony? Yes: □ No: □ Have you used, or are you using any illegal drug(s)? Yes: □ No: □

If you answered yes to any of the three previous questions, please explain:

By filling out this application, I understand that it does not guarantee that I will be an official for SYFA. Futhermore, I understand that the Board of Directors can use my driver’s license number and social security number to perform an NCIC background check. If I am selected to officiate at SYFA, I agree to conduct myself in a manner specified in the rules and by-laws of the organization. I also certify that all the information included in this application is true and correct as of this current date. I accept: ___________________

___ I decline: ___________


Date of Birth: ________________ Driver’s License Number: ______________ State Issued: ___________ Social Security Number: __


Signature of Applicant: ___

__-_ ___

____________________ Date: ___________________

S.Y.F.A. Use ONLY Approved: □ Denied: □ Signature of SYFA Officer:


____ Date: ___________

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