2012 EASTERN ZONE LONG COURSE AGE GROUP CHAMPIONSHIP
APPLICATION TO OFFICIATE
AUGUST 8 - 11, 2012
COLLEGIATE SCHOOLAQUATICSCENTER
RICHMOND, VIRGINIA
Applicant must be a member of USA Swimming and an LSC certified official.
(PLEASE TYPE OR PRINT CLEARLY)
Name: ______LSC: ______
Address: ______Home Phone: ______
City, State, Zip: ______Work Phone: ______
Email Address: ______Cell Phone: ______
Current LSC Certifications: ______
Current N2 Certifications and Expiration: ______
Current N3 Certifications and Expiration: ______
Years/Months at Highest Level ______
ALL APPLICANTS MUST ATTEND MANDATORY OFFICIALS BRIEFINGS BEFORE EACH SESSION OF THE MEET THEY WORK WHICH BEGIN ONE HOUR PRIOR TO THE START OF EACH SESSION
I will serve at all sessions: Yes ___ No ___ I can't serve all sessions. My choices for individual sessions are checked below:
Wednesday13 Over Prelims _____ 12 and under Prelims ______Finals ______
Thursday 13 OverPrelims _____ 12 and under Prelims ______Finals ______
Friday 13 OverPrelims _____ 12 and under Prelims ______Finals ______
Saturday13 OverPrelims _____ 12 and under Prelims ______Finals ______
Shirt Size: ______(S, M, L, etc.) This is not a guarantee. Shirt size is for the host should they choose to provide shirts
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APPLICATION FOR ASSIGNED POSITION: If you would like to be considered for an Assigned Position, please check the appropriate box below. If applying for more than one position, please indicate preference (1,2,3)
Assignment request: ___ Deck Referee ___ Starter ___ Chief Judge ___ Admin. Ref
If you are not applying for an Assigned Position, please check here:___ Stroke & Turn Only
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APPLICATION FOR EVALUATION: If you would like to be evaluated during the meet, complete the following:
I request Evaluation as follows: ___ For Advancement to N2 ___ For Advancement to N3 ( S&T, Initial CJ and DR ONLY)
___ For Recertification ___ For Education
___ Referee ___ Starter ___ Chief Judge ___ Admin Ref ___ Stroke & Turn
Most Recent Evaluation & Evaluator ______(mmddyy) ______
PLEASE PRINT
This application must be received by the Meet Referee by July 25, 2012 in order for the applicant to be considered for specific assigned positions (Deck Referee, Starter, Chief Judge, Admin Ref). Assigned positrions will be notified by the meet referee no later than Aug 1, 2012.
You will receive an E-Mail confirmation of your application. If you do not receive a confirmation within 10 days of submitting your application, call bob rustin, Meet Refereeat the number below.
Mail or E-mail to Bob Rustin, 8208 Chainmale Rd, North Chesterfield, Va, 23235, ,
(804) 387-8736 by July 25th, 2012.
EZ application for Officials AGl Meet 06/12