*First Name:
Middle Initial:
*Last Name:
*Current Street Address:
*City:
*State:
*Zipcode:
*Home Phone:
Work Phone:
Cell Phone:
Fax:
E-mail #1:
E-mail #2:
*Social Security Number:
*Birthdate:	-- dd/mm/yy
*Driver's Lic.State:
*Driver Lic. Exp. Date:

EXPERIENCE

Organization 1
Year(s):
Club Name:
Address:
Positions Held:

Organization 2
Year(s):
Club Name:
Address:
Position Held:

If you are licensed, please specify the type of license(s):

N/A
A
B
C
D
E
E REC
F
G

Have you ever been convicted of a crime of violence?

If yes, please explain:

Have you ever been convicted of a crime against a person?

If yes, please explain:

By submitting this form you must understand the following:

I understand that it is the intent of TYSA to deny any affiliation or relationship to any person who has been convicted of a crime of violence or of a crime against a person. I understand that in applying for affiliation with TYSA or any of its associated teams or positions, the information which I have furnished on this form is subject to verification which may include a criminal history check. I understand that by printing and signing this form I am authorizing TYSA and its officers to verify any and all information. I understand that I authorize release of any information required to verify any information provided on this form. I understand that this disclosure statement will be updated every year.