Officials Background Check Reimbursement

Officials Background Check Reimbursement

Application for reimbursement of background check fees for volunteer officials.
Niagara Swimming will reimburse the amount that exceeds the fee charged by the USA Swimming vendor. Niagara Swimming will only reimburse the background check fees for officials a member club does not otherwise employ.

Unless unattached, a representative of the member club should submit this form.
Contact Information

Please provide contact information for the person making the request.
Club Name*
Enter full club name, if unattached, enter "Unattached."
Name*

First NameLast Name
Title
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Official's Information

Enter the membership information for the official whose background check is being reimbursed.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Background Check Details
Invoice Date*

MonthDayYear
Date
New Member Background Check or Renewal*

New MemberRenewal
Vendor Base Cost
calculated
Tax Rate (Enter as Percent)*
If the tax rate is 8.75%, enter 8.75
Member / Club Responsibility
calculated
Total Cost*
Amount to be Reimbursed
calculated
Receipt and Itemization*

Please upload the receipt provided by Intellicorp (USA Swimming background screening vendor).
Cancelof
Remittance

Please provide to whom to remit reimbursement.
Make Check Payable to:*
All checks must be made out to a club unless unattached.
Send Check to:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Address

This is a new or updated address.
By signing below, you attest that all information provided in your request is true and accurate. In addition, your request is in accordance with the Bylaws and Policies and Procedures of Niagara Swimming, Inc.
Signature*

Clear
Name of Signer*

First NameLast Name
Should be Empty:

Officials Background Check Reimbursement

Contact Information

Official's Information

Background Check Details

Remittance