Referees Personal Officiating Record Form

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NZIHA REFEREES OFFICIATING RECORD NAME: ADDRESS:

DATE

Referee Level: . . . .

PERIOD: . . . . . . . . . . . . . . . . . . . . . . . . . . Scorers & Timekeepers please sign to verify the entry

VENUE

GAME No.

AGE GRADE

TEAMS

SCORER

TIMEKEEPER

The above is a true and accurate record of my officiating: Referees Signature: . . . . . . . . . . . . . . . . . . . . . . . POINTS TO REMEMBER: - Have the scorer and timekeeper verify your officiating. - Sign the form before posting. - Form must be received by Northern Region In-Line Committee Treasurer prior to the 10th of the following month to receive payment by the 30th of that month. - Treasurer & Address: For Treasurers Use: Level 1 Referee all games; Level 2 & 3 Referees all games;

. . . . . Games @ $10.00 = $ . . . . . . . . . . . . . . Games @ $15.00 = $ . . . . . . . . .

Total Amount Owing: $ . . . . . . . . . . . . . . Date Paid: . . . . . . . . . . . . . . . . Cheque No.: . . . . . . . . . . . . . . . .