State Veterans Nomination Form

Veterans State Championships
Rockhampton - July 30 to August 1, 2011

Nominations Close: Thursday, May 12, 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

* Representative History (2010)

* 1st Playing Position

* 2nd Playing Position

The individual HQ nomination forms will be distributed upon selection.

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

ALL PLAYERS ARE EXPECTED TO STAY IN ACCOMMODATION AS ARRANGED BY BRISBANE WOMEN'S HOCKEY ASSOCIATION.

ANY REQUESTS FOR EXEMPTION MUST BE SUBMITTED WITH THIS NOMINATION.

* Indicates Response Required

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