Southern Cross Nomination Form

Saturday, February 12 - Toowoomba
Sunday, February, 13 - Ipswich
Saturday, February19 - Brisbane
Sunday, February 20- Sunshine Coast

Nominations Close: Tuesday, January 18, 2011

* First Name

* Last Name

* Address

* Suburb

* State

* Postal Code

* Home Phone Number

* Mobile Phone Number

* Email Address

* Date of Birth

* Club

* Club Playing Number

* Team Number

* Division

* Did you play in a Premier League or Open Team in 2010?

* 1st Playing Position

* 2nd Playing Position

Nominations subject to BWHA Rules of Association & By-Laws.

* Indicates Response Required