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):
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P.O. Box 64959
Rochester, NY 14624

585.889.4848
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