Club Notification Form for Mistaken Identity

Your Name*

First Last

Your Contact Email Address*

Club Name*

Position in Club*

Match Details

Opposition*

Age/Grade/Division*

Match Date*

Time of Kick-Off*

: HH

MM

Venue*

Offence Reported*

Please Specify Other*

Declaration
I declare that there has been a case of mistaken identity to the above mentioned match.
I declare that the Participant referred to below was not responsible for the Offence reported by a Match Official.

Participant's Name*

First Last

FFA Number*

Can you provide the identity of the Participant who was responsible for the Offence reported by a Match Official?*

Yes
No

Participant Name*

First Last

FFA Number*

By checking the box below, I declare that:*

1. I am authorised to make this statement on behalf of the Club.
2. The information in this statement is accurate to the best of my knowledge.

Acknowledgement*

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.

Club Notification Form for Mistaken Identity

Club Notification Form for Mistaken Identity

Match Details

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