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CERTIFICATE OF INSURANCE REQUEST FORM

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					        CERTIFICATE OF INSURANCE REQUEST FORM

In some cases, the owners or operators of game and practice facilities require
proof of insurance before allowing member organizations to use those
facilities. Association Insurance Commissioners may order Certificates of
Insurance by submitting the following written request to the State Office.

Requested by:

SOUTH TEXAS YOUTH SOCCER ASSOCIATION
15209 Highway 290 East                                      Manor, TX 78653



Association/League or Club (Print name of association and club requesting the certificate)



Print Name of Person Requesting Certificate


Telephone (Daytime)                                            Email



Certificate Holder (Property Owner, City, County, Parks/Rec. Dept., Township, University)


Address


City , State, Zip


Attention



Signature of Association Insurance Commissioner                                              Date

------------------------------------------------------------------------------------------------------------


STYSA State Office Verification Signature                                                    Date



Last Updated: 10/08/01

				
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