Amherst Youth Hockey

2017-18 Referee Statement of Interest Form

*Complete all shaded cells

Name
Address
City / State / NY / Zip
Phone
Date of Birth
E-Mail
What team(s) / organization will you play on / for this season?
Place an “X” Next to the Appropriate Number
Number of Years Officiating: / 0
1
2
3
4
USA Hockey Officials Membership # / (If you are a returning official)
Place an “X” Next to the Appropriate Answer
Do you belong to any other referee group(s) / Yes
No
Referee Group(s) Name You Belong to:
If Yes; List the Referee Groups / 1
2
3
If you are a new applicant; who referred you to Amherst Youth Hockey?
List Name Here:
If you are a new applicant, please list the names and phone numbers of three references, preferably with Amherst Youth Hockey:
Name : / Phone:
Name: / Phone:
Name : / Phone:
Why do you want to be a referee?

Submitting an application to any group is NOT a guarantee of acceptance.

If accepted, there is no guarantee on the number of games you will be assigned to work.

Amherst Youth Hockey reserves the right to limit the number of applicants accepted and to reject any application.

We further reserve the right to give preference to those that have some affiliation with Amherst Youth Hockey.

For those accepted for recommendation to NYSHOA by Amherst Youth Hockey, there will be a mandatory meeting for you to attend with NYSHOA (Date and time to be provided) to review the organization process and procedures.

Anyone paid $600.00 or more during any calendar year will be required to provide their social security number and will be issued a 1099 form.

Complete this form and mail it to:

Glen Aichinger

131 Valley Brook Ln.

East Amherst, NY 14051

Or save your completed document and e-mail it to: