Supply all information requested for form to be considered. All areas on this form must be completed, unless indicated otherwise by a red *. Failure to complete required areas of the form will prevent submission.

Select One
Female Youth Referee	Male Youth Referee
Referee Association Nominating Official: CVSOA DASOA ECISOA MISOA QCSOA SEISOA SSOA SWIowa --Select One--
Your Name:	Position with association*:
Phone Number:	Email Address:
Nominee Information
Nominee's Name:
Nominee's Address:
City State Zip
Nominee's Phone #: Nominee's Email:
Referee Grade: --Select One-- 9 8 7
Nominee's Date of Birth:
United States Soccer ID#:

Please write a statement on the service and accomplishments that the Referee you have nominated has achieved.

Please submit a picture to the SYRA via email: rcwalaska@mchsi.com

The State YROY winners will be announced at the Iowa Soccer Association’s Annual General Meeting in January. Winners’ paperwork will then be forwarded to the Region 2 Regional Referee Administrator for Regional YROY consideration.