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Prescribed Form 05

"*" indicates required fields

PLEASE NOTE:
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

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

Submission

  • 1. I declare that I participated in the above Fixture.
  • 2. I declare that I was responsible for the Red Card Offence issued against the Participant referred to below:
    • Participant 's Name*
  • 3. I consent to being issued a Notice of Suspension instead of the Participant referred to in paragraph 2 above.
  • 4. I declare that the information in this statement is accurate and to the best of my knowledge.
  • 5. I acknowledge that I may be charged with Misconduct if it is established that 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. Participants MUST submit Prescribed Form 04 at the same time as submitting this Form.
  • 3. Participants should read and consider section 7.3 prior to signing and lodging this form with Football NSW.
  • 4. If Football NSW does not receive properly completed forms by the time specified in paragraph 1, the Participant issued with the Notice of Suspension shall serve the Suspension.
  • 5. Capitalised words used in this document are defined in the Regulations.

    • Submitter Details

    Your Name*
    Digital Signature*