ILLINI BASKETBALL OFFICIALS ASSOCIATION

2012-2013 MEMBERSHIP FORM

(Please fill out completely)

 

Name: ____________________________________  

 

Address: ___________________________________________________________

 

City: ___________________________________  ST ________  Zip ___________

 

Work Phone (___)__________________        IHSA Officials #  _______________

 

Cell Phone  (___) __________________       E-mail ________________________

 

TYPE OF MEMBERSHIP (Check One):

Executive($30) ______          Associate($25) ______

                                     

IHSA Classification (Check One):  Registered ____   Recognized ____  Certified ____

Do you wish to be rated on the top 15 list?   Yes ____   No ____ 

Check the Class(es) You Wish to be Rated on for the Top 15 List:

Girls Basketball _____    Boys Basketball _____

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I acknowledge that, as a licensed official, I am acting as an independent contractor with respect to the schools that I contract games with. Although a member of the Illini Basketball Officials Association (IBOA), I am not considered an “employee” of the IBOA. I shall be solely responsible for, and will not hold the IBOA liable for, any medical, insurance or liability expenses that I may incur, as well as any liabilities concerning federal, state, or Social Security income taxes that may result from my officiating.

 

Signed ___________________________________

 

RETURN FORM WITH YOUR CHECK TO:        Steve Mitze

(CHECK PAYABLE TO IBOA)                             Treasurer – IBOA

                                                                                123 West William Street

                                                                                Monticello , IL  61856

Press the print button to print the form. Mail the form and your fee amount to the IBOA.