WFTDA Application for NSO Certification & Endorsement

Name
League Affiliation (or Independent)
WFTDA Application for NSO Certification & Endorsement
Derby Name
© 2012 Women's Flat Track Derby Association (WFTDA)
Section 1: Applicant Information
E-mail Address
WFTDA/USARS #
Section 2: Requested Certification Level
Please check the boxes that apply. Appropriate supplemental documents must also be submitted in order for this application to be
considered complete. Applicants seeking Level 3 certification or higher must possess a level of certification that immediately
precedes the level at which they are applying (e.g. a Level 3 NSO, having held Level 3 certification for one (1) year, may apply for
Level 4).
Not Applicable:
Applying for endorsement
only
Note: only Level 2 or higher certificants
may apply for endorsements
Level 1:
Attendance at a WFTDA
Officiating Clinic
Passed Interleague
Officiating Clinic Exam
NSO Certification Rules
and Procedures Test
Experience as an NSO in
five (5) bouts, regulation
and/or sanctioned
Signed WFTDA
Officiating Code of
Conduct
Application for
Certification
Bout Experience (see
Section 4)
Level 2:
Three (3) NSO
Performance
Evaluations must be
turned in
NSO Certification Rules
and Procedures Test
Signed WFTDA
Officiating Code of
Conduct
Application for
Certification
Bout Experience (see
Section 4)
Level 3:
Must have officiated at
least five (5) WFTDA
Interleague bouts
(regulation and/or
sanctioned) prior to
application
Five (5) NSO
Performance
Evaluations must be
turned in
NSO Certification Rules
and Procedures Test
Received at least one
(1) NSO Certification
Endorsement
Signed WFTDA
Officiating
Code of Conduct
Bout Experience (see
Section 4)
Level 4:
Must have officiated at
least seven (7) WFTDA
Interleague bouts
(regulation and/or
sanctioned) prior to
application
Seven (7) NSO
Performance Evaluations
must be turned in; three
(3) of those Performance
Evaluations must be from
a Head NSO, two (2)
must be from a Head
Referee
Letter of recommendation
from at least one (1)
Level 3 or higher certified
official (NSO or referee)
NSO Certification Rules
and Procedures Test
Received at least two (2)
NSO Certification
Endorsements
Signed WFTDA Officiating
Code of Conduct
Bout Experience (see
Section 4)
Phone #
Date
Level 5:
Must have officiated at
least seven (7) WFTDA
Interleague bouts
(regulation and/or
sanctioned) prior to
evaluation, one (1) of
which must be a WFTDA
tournament
Seven (7) NSO
Performance Evaluations
must be turned in; three
(3) of those Performance
Evaluations must be from
a Head NSO, two (2)
must be from a Head
Referee, the final two (2)
may come from any
source
Three (3) letters of
recommendation from at
least three (3) Level 3 or
higher certified officials,
one(1) of which must be
a certified NSO or referee
NSO Certification Rules
and Procedures Test
Received four (4) NSO
Certification
Endorsements
Previous experience as
Tournament Head Non-
Skating Official at a
WFTDA Tournament or
equivalent
Signed WFTDA Officiating
Code of Conduct
Bout Experience (see
Section 4)

Section 3: Certification Endorsements
Please check the boxes that apply. Appropriate supplemental documents must also be submitted in order for this application to be
considered complete. Applicant must have Level 2 NSO Certification or higher to be eligible.
Not Applicable:
Applying for certification
only
Head NSO (HNSO):
Verification of passed
Head NSO
Endorsement Rules
Test
Three (3) Head NSO
Performance
Evaluation forms from
WFTDA member
leagues
Proof of WFTDA NSO
Certification
Penalty Tracking (PT):
Verification of passed
Penalty Tracking NSO
Endorsement Rules Test
Twelve (12) Penalty
Tracking NSO
Performance Evaluation
forms from WFTDA
member leagues. The
Twelve (12) evaluations
must include a minimum
of Three (3) Penalty
Tracker Performance
Evaluations, Three (3)
Penalty Wrangler
Performance
Evaluations, Three (3)
Inside White Board
Performance
Evaluations, and Three
(3) Outside White Board
Performance Evaluations
Proof of WFTDA NSO
Certification
© 2012 Women's Flat Track Derby Association (WFTDA)
Penalty Management (PM):
Verification of passed
Penalty Management
NSO Endorsement Rules
Test
Nine (9) Penalty
Management NSO
Performance Evaluation
forms from WFTDA
member leagues. The
Nine (9) evaluations must
include a minimum of
Three (3) Penalty Box
Manager Performance
Evaluations, Three (3)
Penalty Box Timer
Performance
Evaluations, and Three
(3) Lineup Tracker
Performance Evaluations
Proof of WFTDA NSO
Certification
Section 4: Bout Experience Requirements
Score and Timing (ST):
Verification of passed
Score and Timing NSO
Endorsement Rules Test
Nine (9) Score and
Timing NSO
Performance Evaluation
forms from WFTDA
member leagues. The
Nine (9) evaluations must
include a minimum of
Three (3) Scorekeeper
Performance
Evaluations, Three (3)
Scoreboard Operator
Performance
Evaluations, and Three
(3) Jam Timer
Performance Evaluations
Proof of WFTDA NSO
Certification
Please submit with this application a bout resume that lists as many bouts as possible; for each bout, include:
• The date of the bout
• Whether it was WFTDA Regulation, Sanctioned, or Tournament play, your position, witness or contact person and their
o E-mail or phone number
• Name of the Head Referee, Head NSO, Tournament Head Referee or Tournament Head NSO, and the participant teams
(e.g. Carolina All-Stars vs. Tucson, Copper Queens)
• When submitting this resume, please give it an appropriate name
o (e.g. “Keanu Heaves_Level_1_John_Smith.pdf”).
1
2
3
Name League Affiliation
Section 5: Letters of Recommendation (Levels 4 and 5 Only)
Contact Information (e-mail address and/or phone number) Verified by (WFTDA Committee use only)
Name League Affiliation
Contact Information (e-mail address and/or phone number) Verified by (WFTDA Committee use only)
Name League Affiliation
Contact Information (e-mail address and/or phone number) Verified by (WFTDA Committee use only)
Role
Role
Role