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Date: ________________________

YYYY / MM /DD

Name: ______________________ ____________________________

FAMILY NAME GIVEN NAMES

Address: ___________________________________________________

NUMBER STREET NAME AVE/ROAD/STREET/etc.

Mailing: ________________________________________ [If different from above]

NUMBER STREET NAME AVE/ROAD/STREET/etc.

__________________________ ______ ________

CITY NAME PROVINCE POSTAL CODE

FIFA / National / Nom. National ______________________

CURRENT REFEREE STATUS [CIRLE ONE] PROVINCIAL SOCCER ASSOC. REGISTRATION NUMBER

Are you a member of your Provincial Soccer Referees’ Association? o YES o NO

If "YES", name of Branch & Association: _________________________________

If "NO", please explain: ________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Are you a member of the Canadian Soccer Referees’ Association? o YES o NO

If "NO", please explain: ________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Name of the International event you plan to attend and apply the Grant Funds:

____________________________________________ _____________________

NAME OF EVENT and LOCATION DATE(S) OF THE EVENT

_____________________________________________________________________

[DESCRIBE BRIEFLY WHAT YOU KNOW OF THE EVENT AND WHAT ARE YOUR EXPECTATIONS FOR ATTENDING.]

_____________________________________________________________________

_____________________________________________________________________

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Submit completed Application Form – along with supporting material – to: CSRA Secretary