Application Form & Agreement – Local Futsal Centre Application Form & Agreement - Local Futsal Centre 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*Max. file size: 15 MB.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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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 Facebook Contact Person of Applicant* First Last Contact Person Phone Number (mobile)*Contact Person Phone Number (office)Contact Person Email Address* Alternative Contact Person Email Address Which form of Futsal will you be delivering?* Select All Local Futsal Competitions Futsal Tournaments Futsal Development Programs Gala Days Futsal Academies Other Please supply details: 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you have your own Competition Regulations?* Yes No If yes can you provide a copy of the regulationsMax. file size: 15 MB. 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)Any/all Local Futsal affiliates will need to request sanctioning from FNSW for all or any of the above programs / competitions. This is for insurance purposes and all registrants will need to register under the relevant affiliate to the correct set up package within PlayFootball.* Yes - I understand I need to request sanctioning from FNSW 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