2009 Nassau County Women’s Lacrosse

Officials Association

Member Profile

 Member Name: ____________________________

 Address: ____________________________________________ 

                      ____________________________________________

 Date of Birth: ________________ (required for USL Enrollment)
Home Phone: _____________                 Work Phone:  _____________
Cell Phone:  ________________                       Pager: ________________
Preferred contact phone number: _________________
NCWLOA Membership Start Year: ____________________
US Lacrosse Member Number: ______________________
US Lacrosse Membership Category: ____________________
BOCES Official Number: ____________
Do you officiate another sport through BOCES? Please list:
________________________________________________________________

E-Mail Address: _________________________________________________

                             Help reduce our postage expense by providing us with your email address. 

Please complete and return to the attention of:

 Gary O'Connor
159 Willow Street
Garden City, NY 11530