Nomination - Individual

Nomination - Individual

For O40s & O50s - Must be submitted by 16th April 2010.

For 045s & O55s - Must be submitted by 28th May 2010

LEGEND

Please note the asterisk beside the boxes down the form relate to the following information .

* Nominating For:

Tick one only - submit a separate form for each age division you are nominating for. (Eligibilty: eg. for 40+ must have turned 40 by 31 Dec 2010. For 45+ must have turned 45 by 31 December 2010 etc)

** 2010 State Championships Playing Particulars - This is for the State Championships indicating which team you are playing for and preferred team position.

*** Please list major achievements and particulars of your recent playing career (indicate year selected)

**** I have read and understood the 'Hockey Queensland Nomination Details' form as supplied by my Association and I agree to the condition of selection etc determined by Hockey Queensland. Tick the 'Yes I agree' box or 'No I don't agree' box marked with ****


Team You Are Nominating For
Name
Date Of Birth
Address
Home Ph:
Work Ph:
Fax:
Mobile:
Email:
*O35+ Team	<1>
*O40+ Team	<1>
*O45+ Team	<1>
*O50+ Team	<1>
*O55+ Team	<1>
*O60+ Team	<1>
*O65+ Team	<1>
*O70+ Team	<1>
** Team Playing For
** Championships Attending - Ipswich	<1>
** Championships Attending - Bundaberg	<1>
** Preferred Position 1
** Preferred Position 2
** Preferred Position 3
** Preferred Position 4
*** Achievements - Australian Team/Squad
*** State Team/Squad
*** City or Association
*** Current Club, Team & Grade
*** Major Awards Won
**** Terms - Yes, I Agree	<1>
**** Terms - No, I Don't Agree	<1>

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