Sheffield RA Membership Application 2021/22

1. Member details

The information the RA hold about you needs to be accurate and following the RA moving its membership database, many members details are incomplete

We would be grateful if you could help us to update your information by completing this short survey , it should take you no more than 5 minutes to complete.

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* 1. Firstly please let us have your contact information

Name *

Date of Birth

First line of Address *

Post Code *

Email Address

Phone Number *

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* 2. Please indicate if you are:-

	Yes	No
Active referee	Active referee Yes	Active referee No
Newly qualified (less than 1 year)	Newly qualified (less than 1 year) Yes	Newly qualified (less than 1 year) No
FA Observer	FA Observer Yes	FA Observer No
FA Tutor	FA Tutor Yes	FA Tutor No
FA Examiner	FA Examiner Yes	FA Examiner No
FA Mentor	FA Mentor Yes	FA Mentor No
RA Mentor	RA Mentor Yes	RA Mentor No
Would you like a RA mentor assigned to you	Would you like a RA mentor assigned to you Yes	Would you like a RA mentor assigned to you No

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* 3. What is your FAN number

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* 4. What is your current Referee level

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* 5. Are you going to renew your RA Membership for 2021/22

Yes

No - but please keep my contact details on file

No - please delete my details from your database

Please let us know why you are not renewing

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* 6. Date qualified as a referee

If approx enter 01/01/yyyy

Date