23-24 PBBOA Registration

23-24 Registration Form

Welcome to the 23-24 basketball season.
Type of Application*

New Member Application ($50)Annual Renewal for Returning Members ($75)Reinstatement for Former Members ($100)
Have you previously been a member of PBBOA?*

YESNO
# of years officiating*
Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number*
Work Number
PLEASE READ CAREFULLY:I certify that I have not been convicted of a state or federal misdemeanor or felony offense. I further certify that I have not been arrested on a pending state or federal misdemeanor or felony charge and that I have not received deferred adjudication or other deferred sentencing for a state or federal misdemeanor or felony offense. I understand that membership in PBBOA does not guarantee me game assignments, PBBOA does not provide medical insurance coverage, and in accepting game assignments from a local chapter I am acting as an independent contractor.*

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23-24 Registration Form