UMPIRE’S REGISTRATION FORM

UMPIRE’S PERSONAL DETAILS

1. Name in Full : M U H A M M A D N A Z M I
B I N M O H D J A M I L

2. Identity Card No : 9 7 0 4 0 5 - 3 8 - 5 4 3 7

3. Age: 20 Years old

4. Occupation: STUDENT
5. Mailing 59 KAMPUNG SERI MAKMUR 1
Address:
(latest)

Post Code: 3 4 3 5 0 State: PERAK

6. Email Add: nazmijj@gmail.com

7. Contact No: 0 1 7 3 6 6 1 4 1 1
Tick ( ) in appropriate column:
Umpire Status : FIH PUL Gred 1 World Cup / Olimpic
(at present)
Class 1 Class 2  Class 3 Year passed Theory Exam: 2017

I would like to be involved in  Outdoor Hockey / Indoor Hockey / Both Category

I, hereby agree that all information given is true. I am aware that MHCUC has the right to reject my application
at any time should it be found any false details have been given.

( ................................................................) Date: 29/11/2017

Umpire’s Signature

ENDORSED BY STATE UMPIRES’ BOARD APPROVED BY MHC UMPIRES’ COMMITTEE

( ................................................................) ( .....................................................................)
Chairman of State Umpires’ Board Chairman of MHC Umpires’ Committee
Date : Date :
STATE
ASSOCIATION
STAMP