Application Form & Agreement – Local Futsal Centre 2020-2021 Application Form & Agreement - Local Futsal Centre 2020-2021 Step 1 of 3 33% 1. Application Process The Application Process to seek Football NSW endorsement of Community Futsal Competition comprises; Competition Information; and Terms and Conditions. Both of these processes are combined in this document. Prospective Community/Local Futsal Competition Administrators are required to submit this document having answered all questions and executed where required. Upon approval, Football NSW will confirm the agreement with a confirmation letter and return to the Competition Administrator. 2. Submission Each Applicant is required to complete this application process: This form must be completed by an authorised person of the Applicant. By submitting the form, the Applicant will be deemed to have reviewed, acknowledged and agreed to the terms and conditions set out in the form without reservation or variation. Should you require any assistance in completing this form please contact the following Football NSW employee: Jordan Guerreiro Email: jordang@footballnsw.com.au Telephone: (02) 8814 4465Name of Applicant (i.e legal entity name)*ABN of Applicant*Designation of Applicant*Private Operator Occupying a CentreFutsal Premier League Club ( FPL & FPL2)Council Facility Administering CompetitionsFootball Association as a Competition AdministratorNot for Profit OrganisationNote: All Applicants must be a registered entity i.e. a body corporate registered under the Corporations Act 2001 or an incorporated association registered under the Associations Incorporation Act 2009 (NSW).Host Applicant Logo*Applicant Postal Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Host Applicant Website* Please ensure you include the following format when entering 'http://www....Host Applicant FacebookContact Person of Applicant* First Last Contact Person Phone Number (mobile)*Contact Person Phone Number (office)Contact Person Email Address* Alternative Contact Person Email Address CompetitionsPlease indicate the Gender and Age Grades you propose to conductAge Grade / Format /Division / Day*For example - Please indicate the Format(s) you propose to conduct for example, Mixed Seniors, 2 Divisions, Tuesday Nights.Venue Name*Venue Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Number of Courts at Host Centre*Number of Dressing Rooms at Host Centre*Do You Have Access to a Canteen*YesNoYes - However Operated by the VenueDo you have access to a medical facilities (i.e. medical kit, medical room etc.)?*YesNoIndicate the competition dates for your competition year* i.e. commencement and conclusion dates for each competition.Untitled*MondayTuesdayWednesdayThursdayFridaySaturdaySundayDo you have your own Competition Regulations?* Yes No If yes can you provide a copy of the regulations Additional Resources and CompetitionsWould you like to be contacted about the Futsal Cup or Community Futsal Competitions run by Football NSW for your local teams to enter*Yes - For both Juniors & SeniorsNo - Only for SeniorsNo - I wish to receive this informationPlease indicate if you would like any of the following resources:*Promotional and Marketing MaterialModel Disciplinary and Regulation ProcessesMy Football Club Registration GuidelinesAccess to\ Competition ManagementModel team sheetsInformation on Coach and Referee CoursesNone of the aboveAre you interested in Local Futsal Champions of Champions? ( knockout competition)?*YesNoMaybe - Please provide more informationAcknowledgementI,* First Last Insert your nameIn my capacity as*Insert title)READ HEREI have read and agreed to the above terms and conditions:* Yes - I have read and agreed to the above terms and conditions: I also acknowledge and agree to the following: I am a person who is authorised to sign this form on behalf of the Administrator; the Administrator agrees to comply with the requirements and obligations set out in this form; on behalf of the Administrator, I have read and understood the form in relation to the Futsal Local Centre structure; and on behalf of the Administrator, I have completed this form to the best of my knowledge and ability and the contents of my submission are true and correct.Digital Signiture* First Last