Date of Submission * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year2020202120222023 Year General Information State Coordinator Position Applying For: * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Game Applying For: * Men's Game Women's Game First Name * Last Name * US Lacrosse Member Number Primary Email Address * Mobile Phone Number * Home Address - Street * Home Address - City * Home Address - State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Home Address - Zip Code * Officiating Information Are you an active official? * - Select -YesNo Are you a Certified Trainer in your area? * - Select -YesNo Are you a Certified Observer in your area? * Yes No Are you an assigner in your area? * - Select -YesNo What levels have you officiated? (Check all that apply) Youth High School College Post-Collegiate What other officiating leadership positions have you held or currently hold? Additional Information Why do you want to be the US Lacrosse State Coordinator for your area? Tell us a little bit more about your professional background. Tell us a little bit more about your officiating background. Please share your involvement with the development of lacrosse officials. What other skills do you possess that would make you a good candidate for this position? References Reference 1 First Name * Last Name * Relationship * Primary Phone Number * Primary Email Address * Reference 2 First Name * Last Name * Relationship * Primary Phone Number * Primary Email Address * Reference 3 First Name Last Name Relationship Primary Phone Number Primary Email Address By completing this questionnaire, I indicate my desire and qualifications to serve as a State Coordinator for US Lacrosse. * Yes No Applicants selected to serve within US Lacrosse Officials National Structure must undergo a criminal background check. Leave this field blank Submit