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Team Roster Form

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					                                                ACIS Basketball National Championships
                                                          NC State Univeristy
                                                         April 30 - May 2, 2010
                                                 *** Enrollment Verification Form ***
        **An origianl Enrollment Verification Form must be received by Friday April 16, 2010 to avoid a late fee**
                                                           Team Information
     Team Name and College:
                                   Collegiate               Collegiate                    Club                    Club
     Division :                     Men's                   Women's                       Men's                  Women's
     (Check One)
                                                   Team Representative Inforamation
     Name:                                                                 Email:

     Address:                                                             Phone:
                                                                          Association with Team:      Player    Coach      IM Staff
                                                                               (please circle)

                                                        Enrollment Verification
The minimum requirement for eligibility is 1/2 full-time enrollment for undergraduate students, a minimum of six (6) credit hours for
graduate students, or full-time faculty/staff employees at the University. Note: If a player is a graduating senior, and taking less than
the required hours to fulfill their graduation requirements, submit a letter from the registrar along with the registration materials
stating that the player will be graduating the same term as the event
                      Players Legal Name                                         Student Campus ID #                              Eligible

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I certify that the above ____ (indicate number of players) names on this roster meet eligibility requirements, assume full responsibility
for their eligibility, and are eligible to participate as a team in intramural sports on my campus. I am also aware that participants must
secure their own personal medical insurance.


             Intramural Director                                                Signature
As registrar, my signature and seal verify that the names on this roster are currently enrolled students or presently employed
faculty/staff at this institution.

                                                                                                                        Registrar's Seal
                   Printed Name                                                 Signature

				
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