EXPRESSION OF INTEREST FORM FOR FIXTURES COMMITTEE

EXPRESSION OF INTEREST FORM FOR FIXTURES COMMITTEE

Prescribed Form 23
Name of Nominee*

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Nominating Member Club/Organisation Name*
Authorised Member Club/Organisation Representative Name
Authorised Member Club/Organisation Representative Position
Notes:

Form to be submitted no later than COB Monday 15 January 2024.
SUBMISSION
Digital Signature*

I certify that the information entered above is true and correct and was entered by myself.
Submission Date*

DayMonthYear
Date
Should be Empty:

SUBMISSION