usab-official-app_renew

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					                                                                                                                          OFFICE USE ONLY
                                                 USA Basketball                                                         Date:
                                             2013 Renewal Application                                                   Application:

                                             USA Basketball Officials                                                   Fee:
                                                                                                                        Physical:
                                                ¨ Please check if address is new
                                                                                                                        Schedule:
                                *****PLEASE PRINT CLEARLY OR TYPE ALL INFORMATION*****
                                              Unreadable forms will not be processed
                            Last Name:                                First Name:                           Middle Initial:
 Information
   Personal




                            Date of Birth:                                                Place of Birth:
                            SSN:                                                          Height:           Weight:
                            Street Address:
   Home Information




                            City:                                                         State:            Zip Code:
                            Phone Number:                                                                   Cell Phone:
                            Fax Number:                              Email Address:
                            Business Name:                                                 Occupation
                            Street Address:
   Work Information




                            City:                                                          State:           Zip Code:
                            Telephone Number:                                              Fax Number:
                            Email Address:
                            Years of Experience:                  Gender Officiate Most:        Men         Women Both
   Officiating Experience




                            List the top 5 officiating                               1.
                            associations/conferences in which you                    2.
                            receive assignments. (#1 being where you                 3.
                            officiate the most and #5 being where you                4.
                            officiate the least)                                     5.
   Signature




                            Signature:                                                    Date:

 Attach the following to the application and submit to Anna Brown at USA Basketball no later than
                                          December 14, 2012:
   1. Renewal fee in the amount of $50. Checks should be made payable to USA Basketball. To pay
      with credit card, please provide information below.
   2. USA Basketball physical examination form or a copy of a physical completed within the last six
      months. Conference or association physicals will be accepted.
   3. Schedule of current officiating assignments.
        Type of Card ¨Visa           ¨MasterCard        ¨American Express       ¨Discover
                            Note: $1.50 processing fee will be added to $50 renewal fee
Information
Credit Card




                            Credit Card Number:                                               Expiration Date:
                            Name on card:                                                 Signature:
                            Billing Address:
Office
 Use                        Record:                                   Amount:                               Approval:

				
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