FORM X Role Protected

Namerequired

First Name

Last Name

Email Address

Phone Numberrequired

The phone number entered could not be formatted, but will still be saved upon submission.

Street Addressrequired

City/Townrequired

STATErequired

NY

PA

Canada

Zip Coderequired

List name of others officials if knownrequired

Select 1

Date of Gamerequired

Must contain a date in MM/DD/YYYY format

Arbiter Game#required

Do not enter 103437 - that is Section VI account# (Must contain only numbers)

Scheduled Start Timerequired

Home School

Private School Name

Non-Section VI School

Away School - If known

Did you complete a voucher

Yes

No

*Important Amount placed on Voucher:*

Select Specific Problem(s):*Please select all that apply (maybe more than one)required

Details of the Problem*required

Date this report is filedrequired

mm/dd/yyyy (Must contain a date in MM/DD/YYYY format)

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