Prescribed Form 04

"*" indicates required fields

Unless a Team Official has indicated on the team sheet that a Participant has been mistakenly identified, your challenge will not be accepted
(see section 7.3(a) and (b))

Your Details

Full Name*

Match Details

For example: National Premier Leagues NSW Men's = 1st Grade
DD slash MM slash YYYY
Time of Fixture*


1. I declare that the following Participant of my Club was responsible for the Offence:
Offender's Name*
  • 2. I declare that the information in this statement is accurate and to the best of my knowledge.
  • 3. I acknowledge that I may be charged with Misconduct if it is established that the contents of this statement are incorrect and amount to an abuse of process.
  • Notes:
  • 1. Please submit this form by 4pm the next working day after the completion of the match.
  • 2. In addition to submitting this form, please submit one of the following forms at the same time:
  • a. Prescribed Form 05 by the Participant actually responsible for the Offence;
  • or
  • Prescribed Form 06 by your Club identifying the Participant responsible for the Offence;
  • and
  • b. Any other evidence which may support your challenge.
  • 3. Participants should read and consider section 7.3 prior to signing and lodging this form to Football NSW.
  • 4. If Football NSW does not receive a properly completed forms by the time specified in Note 1, you are deemed to have committed the Offence and will be issued with a Notice of Suspension.
  • 5. Capitalised words used in this form are defined in the Regulations.
  • Your Name*
    Digital Signature*