UPGRADE REQUEST
Please fill out the following form. Please note: all applications must be submitted prior to March 31st for any upgrades to this year's season.
Applicant Information
Applicant Name:
Email:
District:
Desired Level:
USSF Affiliated Career Game Count
Youth U16 & Below: Referee:
AR:

U17 or Higher Youth: Referee:
AR:

Adult D1 or Higher: Referee:
AR:

Other USSF Adult: Referee:
AR:

Other Referee Accomplishments
Please List Your 5 Highest Level Games As A Referee (past two years):
#1: Date:
League/Tournament:
Age/Division:
Game Length (min):

#2: Date:
League/Tournament:
Age/Division:
Game Length (min):

#3: Date:
League/Tournament:
Age/Division:
Game Length (min):

#4: Date:
League/Tournament:
Age/Division:
Game Length (min):

#5: Date:
League/Tournament:
Age/Division:
Game Length (min):
Please List Your 5 Highest Level Games As An Assistant Referee (past two years):
#1: Date:
League/Tournament:
Age/Division:
Game Length (min):

#2: Date:
League/Tournament:
Age/Division:
Game Length (min):

#3: Date:
League/Tournament:
Age/Division:
Game Length (min):

#4: Date:
League/Tournament:
Age/Division:
Game Length (min):

#5: Date:
League/Tournament:
Age/Division:
Game Length (min):

Please Write A Brief Paragraph Stating Why You Seek An Upgrade:
Digital Signatures
Enter Your Initials (this will constitute as your electronic signature)
Recommended By (Local Contact or SYRA - Can be any District RefereeAdministrator, Assessor, Instructor, Assignor or the SYRA):

CONTACT
WNY REFEREE
Contact Us
P.O. Box 64959
Rochester, NY 14624

585.889.4848