Club Name:

Sunday Team Name:

Saturday Team Name:

Secretary's Name:

Work No.:

Home No.

Email:

Address in Full:

COMMITTEE

NAME

ADDRESS

PHONE NO.

Chairperson:

Vice Chairperson:

Asst. Secretary:

Treasurer:

Asst. Treasurer:

Other Committee Mem

1.

2.

Referee Liaison Officer:

Emergency Contacts:

1.

Mobile:

Please ensure contacts     are reliable

2.

Mobile:

CLUB PRO - Person submitting reports by email & person to whom texts must go for result

Name:

Phone:

Email:

 Text Name:

Text Mobile

DELEGATES

Delegate meeting are compulsory.  Enter a panel of four of your club representatives            a maximum of two can attend.  Only reps stated are allowed to attend.

1.

2.

3.

4.

FIRST AID

A club must have First Aid Kit, which must be present at all, matches involving the club and one person must be responsible for same. PERSONS IN CHARGE OF FIRST AID. Persons who have completed defibulator course and follow up.  Please enter names.

1.

2.

3.

4.

SUNDAY TEAM APPLICATION DETAILS

Team Name:

Alternative Ground & Location

Main Ground & Location

Team Managers Name:

Address:

Changing Facilities:

Phone No.: H

M

Team Colours First Choice

Jersey:

Shorts:

Socks:

Team Colours Second Choice

Jersey:

Shorts:

Socks:

SATURDAY TEAM APPLICATION DETAILS

Team Name:

Alternative Ground & Location

Main Ground & Location

Team Managers Name:

Address:

Changing Facilities:

Phone No.: H

M

Team Colours First Choice

Jersey:

Shorts:

Socks:

Team Colours Second Choice

Jersey:

Shorts:

Socks:

GROUND DETAILS

Does your Club own your pitch?

Yes

No

If NO please attach relevant documentation to guarantee that you will have full & sole use of the grounds for the coming season.

INSURANCE

Please attach copy of your Public Liability Policy and Personal Accident Policy.  If Policy is to be renewed after the date that the forms are to be returned.  Please send copy of last year's Policy and forward copy of new Policy upon renewal.

PLEASE NOTE

•1.     The executive committee has the authority to grant or refuse an application by a club.

•2.     Please ensure all parts of form are complete.

•3.     It is compulsory that you attach the following:

•(a)           Copy of Public Liability Insurance and Personal Accident Insurance.

•(b)          Declaration for use of pitch for season.

THIS APPLICATION MUST BE SIGNED BY THE CLUB SECRETARY

Signed:

Date: