Fillable Printable Printable Checkbook Register
Fillable Printable Printable Checkbook Register
Printable Checkbook Register
2014 ASA Umpire Registration and Clinic Registration Form
Payment of the Umpire Registration, Rules Clinic and Mechanics Clinic Fees may be combined in one payment. Please complete
WITH A 3) COPY OF A VALID ID AND MAIL ALL 3 TOGETHER with appropriate fees to the address that appears
below. Umpire registrations will be accepted at all SoCal ASA umpire clinics, and may also be hand-delivered to any
member of the SoCal ASA UIC Staff.
Please Print Clearly
(As listed on your Drivers License)
ST: _________
Check if new Address
Years registered with the ASA: _______ Last umpire school attended/year: NUS __________ Advanced School __________
Umpire Programs: ISF _____ Elite _____ NIF _____ Medals: Blue _____ Bronze _____ Silver _____ Gold _____
Number of National Championships Assigned: ______ Last National Championship Assigned: Year ______Level ______
By submission of this form I acknowledge my status as an independent contractor, and that I am not an employee of the Southern California ASA or
the Amateur Softball Association of America.
Adult Fees (18 Years Old and Older) Youth Fees (17 Years Old and Younger)
Registration: $60.00
$50.00
$70.00
Rules Clinic: $15.00
Rules Clinic: $15.00
Mechanics Clinic: $10.00
No Fee
Optional Insurance: $25.00
$25.00
A $25.00 fee will be assessed for each check returned by a bank for non-sufficient funds.
Get your registration in early to avoid a late fee.
MAIL All four (4) forms to have your registration processed
1. Completed Registration Form 3. Copy of Photo I.D
2. Background Check Form 4. Independent Contractor Agreement
This information to be completed by a member of the Southern California ASA UIC Staff only
Method of Payment: Check:
Cash:
Book Number: _______________ Year: _________________
District: _________________________________ Processed by: _____________________________
3 things to complete the registration process: 1) this FORM, 2) BACKGROUND CHECK RELEASE FORM ACCOMPANIED
Last Name: _____________________________
First Name:_______________________ Middle Name:_____________
SSN: ____ ___ ___ - ___ ___ - ___ ___ ___ ___
Birth Date:_______________________
Mailing Address: _______________________________________________________________
This is a new address:
City: ___________________________________________________________
Zip Code: ___________
Home Phone: ( )
Work Phone: ( ) _
Cell Phone: ( )
Email: __________________________________________________
If postmarked or
received on or before
January 17, 2014
Registration:
If postmarked or
received after
January 17, 2014
Mechanics Clinic:
Optional Insurance:
Total Paid: $_______________ Total Paid: $_______________
You may attend ANY scheduled Rules Clinic and any Mechancis Clinic.
Fee Payments to: Southern California ASA
Post Office Box 97
Lemon Grove, California 91946-0097
Money Order:
Adult: Youth:
