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*
Untitled
Match Date*
Date Format: DD slash MM slash YYYY
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.

Match Details