If you are an officer of CSAN or of a league affiliated with CSAN, please print a copy of this form, fill it out, sign the bottom and then mail it to:   Dr. Thomas P. Moore, P.O. Box 8704-NPS, Monterey, CA  93943-8704.  Please include ONLY that information that you want published on the CSAN website.

First Name:                                                              

Last Name:                                                               

(  ) Mr. (  ) Mrs. (  ) Ms. (  ) Dr. (  ) Other:

Street Address:                                                                                       

Apartment Number:                 

City:                                        

State: CA

Zip Code:                            -                 

Home Phone (including area code):                                                    

Work Phone (including area code):                                                    

Cell Phone (including area code):                                                       

Pager Number (including area code):                                                 

E-mail address:                                                                                 

Name of League:                                                                                                 

Your Title or Position:                                                                                          

League's website address:                                                                                                      

I hereby grant permission to California Soccer Association North (CSAN) to put the data shown above on the CSAN website.

Signature:                                                                             Date: