PORTLAND INDOOR SOCCER, INC.
418 SE MAIN ST
Portland, Or  97214-3416
503.231.6368

REFEREE INFORMATION

NAME( please print):

______________________________________________________


ADDRESS:

 ______________________________________________________


HOME PHONE:

WORK PHONE:
(      )  _____________________________________

(      )  _____________________________________


Is it okay to call you at work?_____ 


SOC SEC NO: _____ - ____ - _______ ( We must issue a 1099 if you gross $600 or more)                       


NOTE: 


You must be (or have been) certified as a soccer official (outdoor or indoor)
in order to referee at Portland Indoor Soccer.

EXPERIENCE LEVEL: Check all that apply
             ____ youth recreational
             ____ youth classic
             ____ high school
             ____ collage
             ____ outdoor men
             ____ outdoor women
             ____ outdoor coed
             ____ indoor youth
             ____ indoor adult