Please Print – Fill Out Completely

Name _________________________ Phone _____________________

Address ___________________________________________________

City_____________ State _________________ Zip _______________

School ________________________ Date of Birth ________________

Position Desired (circle one)

Basketball Ref                 Biddy Basketball         Scorekeeper

Have you worked for Newtown Youth Basketball Association,

Inc. in the past (circle one)?              Yes         No

If Yes; how many years _____

In what  capacity __________________________________________

___________________________________________________________

Signature                                            Date

Attach working papers to this form and return to: NYBA Inc,

Referee Coordinator, P.O. BOX 196, Newtown, Ct., 06470