refreimbursement

                         NEW REFEREE REIMBURSEMENT FORM

Name ___________________________________________________________

Address ___________________________________________________

             ____________________________________________________

Phone number __________________________________

ROSRA Referee number ____________________

Please reimburse my $25 ref class fee. I centered the following ten games:

        Day             Date             Time            Field                                      Age group

1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
4. _________________________________________________________________
5. _________________________________________________________________
6. _________________________________________________________________
7. _________________________________________________________________
8. _________________________________________________________________
9. _________________________________________________________________
10. ________________________________________________________________

I certify that I centered the above ten games and am therefore entitled to a $25 reimbursement of my ref class fee.

Signature ______________________________________ Date ______________

Mail form to:

ROSRA
503 Melody Court
Royal Oak, MI 48073

This form is due within two weeks of the end of the season. Checks will be mailed out after games are verified.