Manitoba Soccer Referees Association

Registration
Name:		Birthdate:	/ / (mm/dd/yy)
Address:		Postal Code:
Phone #'s:	(home) (work) (cell)
E-mail:		Referee #:	(n/a if not assigned)

Returning referees to register before June 1st, 2010. After June 1st a late fee of $10.00 will apply.
Please check one: Senior Member ($40) Associate Member ($15)
Please check one: Renewal New Member

What year did you first join MSRA?
*NEW Did you officiate prior to becoming an MSRA member?		Please check one: Yes No

If yes, what year did you begin?
Year
Level
Youth	Senior

*Please not your MSRA membership fee* will be deducted off your cheque.**
Please Note: Game levy, whether referee or assistant referee, is $1 off per assignment.

Please answer the following questions and provide details for any question you answer with "yes".
1. Are you presently under suspension from any soccer authority? Yes No
Details:
2. Are you now, or do you intend to be affiliated with any registered soccer club as: a) a player Yes No b) board member/team official Yes No
Team:		League:
Division:		Position:
I have completed the MSRA Membership Application accurately and honestly. As a member of the MSRA, I will abide by the constitution of the MSRA along with its rules and regulations. I will abide by the MSRA and the CSA Code of Ethics at all times.

Privacy of Information: Personal information provided here will be used solely for the purposes of the MSRA, its members, other professional associations, and league officials for the purposes of communicating professional requirements and game assignment information. Leagues and associations will be reminded to respect the privacy and confidentiality of information provided. Any changes to this information, including any known loss, misuse, or disclosure to other 3rd parties is to be reported to the MSRA immediately.

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