Name:                                                      Title:                                 Date of Birth:

Partners Name:                               NRAS Level:                    Folio No. (New members only)

Address:

Postal Address (If Not Above)

Work Suburb:

Contact Details

Home: ____________ [  ] Work: ____________ [  ] Mobile: ____________ [  ] Fax: ____________ [  ]

Email: _______________________________ [  ]  (For Newsletters)

Membership categories (tick as appropriate):

[ ] Junior or [ ] Senior [ ] Active or [ ] Non-active [ ] Life member

I agree to adhere to the Object and Rules, and Codes of Conduct, of the Newcastle Coalfields Rugby League Referees Association, the Newcastle Rugby League, and, where applicable, the CRLRA, the NSWRA and the ARLRA.
Signed:                                                         Date:

Accreditation Level (tick as appropriate):

[ ] Referee in Training [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Level 4

I am available at these times (tick as appropriate):

[ ] Weekdays daytime [ ] Weekday evenings (after _________ pm)

[ ] Friday evening (after _________ pm)

[ ] Saturday morning [ ] Saturday afternoon [ ] Saturday evening

[ ] Sunday morning [ ] Sunday afternoon

I am available to referee (tick as appropriate):

[ ] Mini-Mod [ ] Schoolboys /  International ( ) Juniors & [ ] Senior Grades

Please indicate details of any teams in which an immediate family member is involved as a coach, manager, trainer or player.
Details of any special considerations or restrictions to your availability.

**This form is only to be returned to: The CEO PO Box 2193 Dangar NSW 2309.

** DO NOT give this form directly to a Director of Referees.