Officials Registration Form

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Form 0-1 NO REFUND WEST VIRGINIA SECONDARY SCHOOL
ACTIVITIES COMMISSION CHECK ONE:

2875 STAUNTON TURNPIKE, PARKERSBURG, WV 26104 Renew ______

(Please Print or Type) Transfer ______

OFFICIALS REGISTRATION FORM - 2003-2004 First Yr. ______

Name _________________________________________________________________________________________________________________

(Last) (First) (Middle)

Address________________________________________________________________________________________________________________

(Street or Route)
(City) (State) (Zip)

Home Phone No. ________________________ Business Phone No. _______________________ Registration No.______________________

Local Board ____________________________ Name of Employer ________________________ Occupation __________________________

Birth Date ________________________________ Social Security Number ______________________________________

REGISTRATION FEES: (PLEASE CHECK SPORT OR SPORTS) NOTE: DO NOT SEND CASH!!!!!

Football $28.00 ______ Volleyball $22.00 ______ Soccer $22.00 ______

Basketball $28.00 ______ Baseball $22.00 ______ Swimming $18.00 ______

Wrestling $28.00 ______ Softball $22.00 ______ Track $18.00 ______

TOTAL ENCLOSED $ _____________ INACTIVE FEE $__________________ INACTIVE SPORT _____________________

CHECK # _________________ $10.00 INACTIVE FEE FOR EACH SPORT!! Make check or money order payable to the WVSSAC

NFIOA FEE $4.00 (Must be paid by all Officials)

Registrations shall be postmarked for all sports on or before June 15

REGISTRATION DUE: JUNE 15, 2003 - REGISTRATION FEES PLUS $25.00 LATE FEE IF AFTER DUE DATE

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