State Coordinator Application

Date of Submission *

Month

Day

Year

General Information

State Coordinator Position Applying For: *

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 *

Home Address - Zip Code *

Officiating Information

Are you an active official? *

Are you a Certified Trainer in your area? *

Are you a Certified Observer in your area? *

Yes

No

Are you an assigner in your area? *

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.