SHORT TRACK SPEED SKATING

COMPETITION TECHNICAL OFFICIALS

APPLICATION FORM

MINIMUM QUALIFICATION: All applicants must be currently active officials in Good Standing with their National Skating Federation and Special Olympics Program. Further, an applicant must be certified by the ISU as an International Official, or by their National Skating Federation at its highest rating level. Officials experience with a Special Olympics speed skatingprogram is preferred. The 2013 Special Olympics World Winter Games will require a commitment from 26 January – 6 February 2013.

SELECTION: If selected, the Games Organizing Committee will arrange and provide the cost of direct travel to and from Korea, local transportation to & from competition venues, accommodations and meals. Any travel outside the dates of 23 January - 7 February 2013 will be the sole financial responsibility of the selected official. Anyone unable to meet these requirements, or make this commitment, should not apply.

PROCESSING: Please (1) Print or type in English, (2) Complete in its entirety, information must be verifiable,(3) Retain a copy for your records and(4) Optional: Submit other supporting documentation, references, and other Special Olympics experiences to be considered under separate cover.

SECTION 1 - PERSONAL DATA

Name
Family First Mr./Mrs./Miss/Ms.
MailingAddress
Street / City
State/Province/Country / Postal Code
Phone
(Country code)
Fax / EmailAddress: ______
(Country code)

SECTION 2 - CERTIFICATION INFORMATION

Certifying Organization / Country / Name of Position
Level of Certification / Expiration Date
National Federation
ISU

SECTION 3 - OFFICIATING EXPERIENCE

List the names of two (2) individuals who can be consulted regarding your officiating ability.

Name: / Name:
Affiliation: / Affiliation:
Address: / Address:
Phone: / ( ) / Phone: / ( )
Email address: / Email address:

Number in order of your preference (with 1 your highest priority), the officiating assignment for which you possess outstanding competence and experience.

Starter / Assistant Starter / Referee
Assistant Referee / Finish Line Judge / Competitors Steward
Track Steward / Photo Finish Judge / Chief Finish Line Judge
Chief Timekeeper / Heat Box Steward / Asst. Competitor Steward

List most recent Special Olympicsspeed skatingofficiating experiences

Year / Name of Competition / Assignment

List most recent major competitions(speed skating) officiatedoutside of Special Olympics.

Year / Name of Competition / Assignment

I certify that I am a currently active speed skating official and that the information presented inthis application is true to the best of my knowledge. As part of my application,I grant permission for the Selection Committee to contact individuals, including observers, regarding my officiating experience and ability. I certify that I am in good physical and mental health.

Signature of Applicant Date
Signature of National Director/Executive Director/Designee of Special Olympics Program Date
Name of Special Olympics Program (please print)

Please return by 3 January 2012 to:

Email:

Selection will be made to ensure a diversity balance. Early return of application advised.