(PF 06) - Written Statement by a Club - Mistaken Identity in a Match Official Send-Off Report

WRITTEN STATEMENT BY A CLUB -MISTAKEN
IDENTITY IN A MATCH OFFICIAL SEND-OFF
REPORT (SECTION 7.3)
Prescribed Form 06

PLEASE NOTE:

Unless a Team Official has indicated on the team sheet that a Participant has been mistakenly identified, the challenge will not be accepted

(see section 7.3(a) and (b))

Club Official's Details

Full Name *

First Name Last Name

FFA Number *

Club Name *

Role / Position at Club *

Submission

1. I am authorised to make this statement on behalf of the Club.

2. I declare that there has been a case of mistaken identity in relation to the following Fixture:

Match Details

Opposition Team *

League *

Grade *

Date & Kick off time *

- Month - Day Year

at

: Hour Minutes

3. I declare that the Participant referred to below was not responsible for the Red Card Offence issued by a Match Official during the Fixture.

Participant 's Name *

First Name Last Name

FFA Number *

4. I declare that the Participant referred to below was responsible for the Red Card Offence issued by a Match Official during the Fixture and should be issued with a Notice of Suspension.

Participant 's Name *

First Name Last Name

FFA Number *

5. I declare that the information in this statement is accurate and to the best of my knowledge.

6. I acknowledge that the Club and I may be charged with Misconduct if it is established that contents of this statement are incorrect and amount to an abuse of process.

Notes:

1. Please submit this form by 4pm the next working day after the completion of the match.

2. Participants MUST submit Prescribed Form 04 at the same time as submitting this Form.

3. Clubs should read and consider section 7.3 prior to signing and lodging this form with Football NSW.

4. If Football NSW does not receive properly completed forms by the time specified in paragraph 1, the Participant issued with the Notice of Suspension shall serve the Suspension.

5. Capitalised words used in this document are defined in the Regulations.

Submitter Details

Your name *

First Name Last Name

Your E-mail *

A copy of your submission will be emailed to this address.

Digital Signature *

I certify that the information entered above is true and correct and was entered by myself.

Submission Date *

- Day - Month Year