Premier League & Open Championships Nomination Form

State Premier League & Open Championships 2011 - SHC Brisbane - June 10 to 13, 2011

Nominations Close: Thursday, May 5, 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

* Previous Playing History (2010)

* 1st Playing Position

* 2nd Playing Position

Please tick appropriate square if you wish to nominate for a Queensland team/s:

UNDER 21

SCORCHERS

HQ DEVELOPMENT TEAM

*The Individual HQ nomination forms will be distributed upon selection in a Brisbane team.

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

* Indicates Response Required