23.03.2014 Views

CPY Document Title - FIFA.com

CPY Document Title - FIFA.com

CPY Document Title - FIFA.com

SHOW MORE
SHOW LESS

You also want an ePaper? Increase the reach of your titles

YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.

List of Nominations 2011 ()<br />

<strong>FIFA</strong><br />

For the Came. Forthe WOf~d.<br />

Association<br />

Role:<br />

Ranking<br />

International Referee<br />

Family Name"<br />

International Assistant Referee<br />

First Name"<br />

International Futsal Referee<br />

Popular Name<br />

International Beach Soccer Referee<br />

Maiden Name<br />

International Women Referee<br />

Date of Birth"<br />

International Women Assistant Referee<br />

Place & Country of Birth International Woman Futsal Referee FAST 10:<br />

Correspondence Languages (English. French, Spanish or German)<br />

1st, 2nd, 3rd. 4th choice (E. F, S, G)<br />

Mother language<br />

Other languages<br />

Address<br />

Street", P.O. Box<br />

Postcode, City", State<br />

Country<br />

Tele<strong>com</strong><br />

Work phone<br />

Home phone<br />

Mobile<br />

Fax<br />

E-mail<br />

Refereeing career<br />

1st international A match<br />

<strong>FIFA</strong> referee since"<br />

Best memory in general<br />

International club matches (finals only)<br />

Passport<br />

Passport Number<br />

Place &Date of Issue<br />

Expiration Date<br />

OTHERS<br />

Marital state & number of children<br />

Occupation<br />

General interests, Hobby & Match Ritual<br />

I Routine<br />

Nearest international Airport<br />

MEASUREMENTS<br />

Height (em) Weight (kg) Tracksuit Jersey Short Shoes (UK)<br />

" Compulsory fields!<br />

MEDICAL EXAMINATION<br />

IDate when passed"<br />

PHYSICAL FITNESS TEST<br />

IDate when passed"<br />

I<br />

I<br />

Report created 05.08.2010 15:14 CET<br />

Date:<br />

Signature:<br />

Please return form to <strong>FIFA</strong> Refereeing Department Zurich , Switzerland<br />

Federation Internationale de Football Association<br />

<strong>FIFA</strong>-Strasse 20 P.O.Box 8044 Zurich. Switzerland . Tel: +41-(0)43-2227777 . Fax: +41-(0)43-222 7878 www.fifa.<strong>com</strong>

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!