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Prescribed Form 06

"*" indicates required fields

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

Club Official's Details

Full Name*
Role / Position at Club*

Submission

  • 1. I am authorised to make this statement on behalf of the Club.
  • 2. I declare that there has been a case of mistaken identity in relation to the following Fixture:

    • Match Details

    Example: National Premier Leagues NSW Men's
    Example: National Premier Leagues NSW Men's = 1st
    DD slash MM slash YYYY
    Time of Kick-Off*
    :
    3. I declare that the Participant referred to below was not responsible for the Red Card Offence issued by a Match Official during the Fixture.
    Participant 's Name
    4. I declare that the Participant referred to below was instead responsible for the Red Card Offence issued by a Match Official during the Fixture.
    Participant 's Name
  • 5. I declare that the information in this statement is accurate and to the best of my knowledge.
  • 6. I acknowledge that the Club and 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. Clubs 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*