First Name: Last Name:

Address: Phone:

Work Phone:

City: State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

Age Group and Sex of your swimmer:

E-mail address:

Current Certifications:

LSC Certification Stroke and Turn Starter Referee Number of Years 1 2 3 4 5 6 7 8 9 10+

National Certification N2 None Stroke and Turn Chief Judge Starter Referee-non-starter Referee Expires Dec 31, 2007 Dec 31, 2008

National Certification N3 None Stroke and Turn Chief Judge Starter Referee-non-starter Referee Expires Dec 31, 2007 Dec 31, 2008

I will be applying for a National (N2 or N3) certification evaluation: Yes Application must be received by January 8, 2008.

I will officiate at all sessions: Yes No I can officiate some sessions.

My choices for individual sessions are checked below:

Friday Evening Timed Finals (6:00 PM)

Saturday Prelims (8:00 AM) Saturday Timed Finals (~12 Noon)

Saturday Finals (6:00 PM)

Sunday Prelims (8:00 AM) Sunday Timed Finals (~12 Noon)

Sunday Finals (6:00 PM)

Please indicate pool assignment preference:  (ex. 11-12 boys pool)

I am applying for a specific deck position:

I would be willing to serve as a meet marshal before a session that I’m officiating:

 Yes No

If you have some specific needs or issues please place in comment section.

Trish Mitchell, Referee
piscina@comcast.net