March 19, 2010 Friday

Entry Level Clinic - Council Bluffs
Council Bluffs Community Hall, 205 South Main St, 		6:00PM - 10:00PM 
Contact:
Warren Lee

712-256-1092

warrlee@cox.net

Details:
Continues Saturday

8:00 AM until 5:00 PM

Register:
This is an Entry Level Clinic for individuals looking to certify in this area for the first time. If you are already registered in the state of Iowa as a Referee, Instructor, Assessor, Assignor, Indoor or Futsal Referee, simply enter your Iowa RefLink login information below to register for this clinic. If you do not already have an account, continue to the NEW USER section below...
Username:
Password:


Don't have an Iowa RefLink account yet? Complete the following form to register as a NEW USER.

All areas must be completed unless otherwise indicated or you will not receive credit for attending this clinic.

Important: Information provided below will be used to establish your registration with the USSF, so be sure all information is complete, accurate, and as you want it to appear on your official registration documentation.

Biographical Information
First Name:
Middle Initial: *Optional
Last Name:
Nation of Birth:
Nation of Citizenship:
Gender: Male Female
Birth Date:
Mailing Address
Address:
City:
State:
ZipCode:
Contact Information
Email:
Primary Phone:
Secondary Phone: *Optional
Background Disclosure
Have you ever been convicted of a felony?
     Yes No
If you answered yes, please provide details of the conviction:
     
* Description should include: Court of conviction, title of conviction, description of offense
If you answered yes, please provide the date of conviction:
     Select Date
Account Information
Username:
Password:

*Write your username and password down in a safe place! You will need it to access your account in the future.