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To; The General Secretary,

Tamil Nadu State Chess Association,
Hall No.75, J N Stadium, Chennai-3.

Sir, Sub: Arbiter for Life

I wish to register myself with TNSCA as an Arbiter for Life. I am enclosing an amount
of Rs.500/- (Rupees Five Hundred Only) in cash / by cheque/DD no
……………………Dated……………….…………Drawn on…………………………………Branch of
………………………..Bank. My particulars are:

1. Name : …………………………………………………..

2. Father’s / Husband’s Name : …………………………………………………..

3. Residential Address : …………………………………………………..

…………………………………………………….

…………………………………………………….

Pin code: ……………………………………

4. Title, if any : ……………………………………………………

5. Date of Birth : ……………………………………………………

6. Tel No (with STD Code) : ………………………………………………….

7. Mobile No : …………………………………………………..

8. E Mail ID : ……………………………………………………

9. Languages known : …………………………………………………..

10. District : ……………………………………………………..

11. Recommended by District

Chess Association :…………………………………………………….

The particulars given above are true to the best of my knowledge and belief. I declare
that I shall abide by the rules / regulations / decisions of Tamil Nadu State Chess
Association / All India Chess Federation as the case may be and cooperate with the
officials in officiating as an arbiter. I also declare that I will not officiate as an arbiter
in any tournament / championship not authorized / not recognized by
TNSCA / AICF.

Place:
Date: Signature of the arbiter

Seal of the District Chess Association District Secretary Signature