WOMEN’S SECTOR

WORLD EVENT OFFICIALS APPLICATION FORM

OFFICIALSAPPLICATION AND CONFLICT OF INTEREST FORM

FIL WOMEN’S WORLD CUP 2017

DUE: 1 NOVEMBER 2016

NATIONAL GOVERNING BODY
PERSON SUBMITTING APPLICATION
POSITION IN NATIONAL GOVERNING BODY

1ST RANKED UMPIRE

Name:
Home Address #1:
Street:
City:
State/Province:
Country:
Postal/zip code:
Email:
Cellular/mobile phone:
% time person residesat this address:
Home address #2 (if applicable):
Street:
City:
State/Province:
Country:
Postal/zip code:
Email:
Cellular/mobile phone:
% time person resides at this address:
NATIONALITY:
Citizenship #1
Country:
Citizenship #2 (if applicable)
Country:

ACCREDITATION INFORMATION

Current accreditation (international or national)
Date current accreditation earned:
Date current accreditation expires:

RECENT OFFICIATING HISTORY

Please provide a summary of your umpiring over the past three years, including at a local, national and international level.

Year / Local / National/College / International
2016
2015
2014

CONFLICT OF INTEREST

Applicants for the FIL Women’s World Cup 2017 must declare any interests which may conflict with their role as an umpire at the event.

The applicant should list all interests that relate to their potential appointment as an Umpire. For example, their relationship to any team personnel (personally and professionally), any commercial or business operations, any other related parties (spouses, partners, children, brothers, sisters, parents, grandparents and step relationships that may impact on the assessment), any position they may hold on a National Governing Body.

Where a potential conflict of interest arises, this information will be referred in confidence to the FIL Officiating Chair AND FIL Sector Director for consultation to determine if the conflict requires further attention.

Applicants should immediately inform the FIL Officiating Chair of any changes occurring in their signed Conflict of Interest form. All information will be maintained confidentially by the FIL Officiating Chair.

I declare that I have the following conflicts:

Person / Organisation / Nature of Interest

I declare that the above information is a full disclosure of my business and personal interests in connection with the accreditation and I agree to advise the FIL Women’s Officiating Chair of any changes to the above information from the date of signature to the date of the event.

Signed
Date

Please repeat the above application form for 2nd and subsequent umpires.

Please email to:

Stephen Taylor

FIL Women’s Officiating Chair

Please remember to include a lacrosse CV/resume for each applicant.By 1 November 2016

FIL WORLD EVENT OFFICIALS APPLICATION FORM May 2016| 1