BRITISH COLUMBIA SOCCER ASSOCIATION
#510 - 375 Water Street, Vancouver, V6B 5C6 • Tel: (604) 299-6401 • Fax: (604) 299-9610

FORWARD TO APPROPRIATE AFFILIATE
VISL (div 6) • Scott Metson • Fax: 598-0889 • vladtheimpaler13@shaw.ca
VISL (div 1-5) • Vince Greco • Fax: 360-1648 • vincentgreco@shaw.ca
UISA • Kevin Cowie • Fax: 923-7923 • kc_owie@oberon.ark.com
MIWSL • Stu Power • Tel: 339-6256 • visranorth@shaw.ca

REFEREE’S REPORT REGARDING AN ASSAULT ON A MATCH OFFICIAL

Referee’s Name_________________________ : __________________________Date of Game

Home Team_____________________________vs____________________________Away Team

Venue_________________________________ : ____________________________Competition

Dear Sir: Arising from the above-noted game, I am reporting an instance of......

ASSAULT ON A MATCH OFFICIAL

This action was a case of (check one)

VERBAL ABUSE _____ : _____ PHYSICAL ABUSE

Offender's Name (Please print or type) ____________________________________________________

ID and/or Shirt Number ___________ of the ____________________________________________Team

The incident occured as follows:___________________________________________________________

_____________________________________________________________________________________

Referee (Print) _________________________Address _________________________________________

Tel ___________ Bus ___________ Fax ___________ Signature _________________________________

* To Chairman, B. C. Soccer Association Discipline Committee (within 48 hours)
Contact should also be made with your area President and the Secretary and President of the BCSA