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Centennial Conference
Supervisor of Football Officials … Jim Corpora

2019 FOOTBALL OFFICIATING APPLICATION

A: PERSONAL INFORMATION

Name: Date:

Street Address: City: State: Zip Code:

Cell Phone: E-Mail Address:

Date Of Birth: Height: Weight:

Occupation:

College(s) Attended:

B: FOOTBALL OFFICIATING EXPERIENCE

Number of years you have officiated: High School: College:

Current Collegiate Conference (if applicable):

Do you officiate other sports? Yes No If yes, which other sports?

Baseball/Softball: Basketball: Lacrosse: Soccer: Other:

Below please indicate your top two (2) preferred position preferences.

Referee: Umpire: Short Wing: Deep Wing: Back Judge:

NOTE: Please check here if you are only interested in working as a Clock Operator.

Are there any circumstances or condition(s) which would affect your priority for accepting assignments in the Centennial Conference? Yes No If you answer yes, please explain here:

Officiating Schedule: Please list your VARSITY football officiating schedule from the 2018 season. This should include the date, position worked and the teams involved. I only want Varsity High School, College or Junior College games you worked on the field.

C: REFERENCES

Below, list the names, addresses, and phone numbers of three qualified individuals who have observed your work as a football official. By listing these references, you agree to permit us to contact them.

1. Name_1 Address_1 Phone_1

2. Name_2 Address_2 Phone_2

3. Name_3 Address_3 Phone_3

D: MISCELLANEOUS

Have you ever had a civil judgment against you? Yes No

If yes, provide details

Have you ever been convicted of a crime? Yes No

If yes, provide details

E: ACKNOWLEDGMENT OF TRUTH:

I acknowledge that the above information is accurate and correct.

Signature Date

After you complete the application:

Print the application.

Sign and date at the bottom.

Return your completed application with your $45.00 nonrefundable check made payable to Centennial Conference Football Officials and mail to:

Jim Corpora

Supervisor of Football Officials

The Centennial Conference

3240 South 5th Avenue

Whitehall PA 18052

(C) 610.417.5679

(e-mail) jcumpref@rcn.com

** Please note Applications will be accepted from December 1, 2018 to April 20, 2019.