Old Dominion Umpires Association
Umpire Registration Form

PERSONAL INFORMATION
Form Submissions are Safely Encrypted

Name		Spouse's Name
Date of Birth		Address
Home Phone	() -	(cont.)
Work Phone	() -	City
Cell Phone	() -	State	Zip Code
Email		SSN#	- -

UMPIRE EXPERIENCE AND INFORMATION

Number of Years Umpiring Baseball?	Number of Years Umpiring High School?
Highest level worked?	Level of umpiring I aspire to:

I will be transferring from another umpiring association.

CERTIFICATION OF TAXPAYER IDENTIFICATION NUMBER

The number shown above on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.

I have read and verify that I comply with the CERTIFICATION OF TAXPAYER IDENTIFICATION NUMBER.

CONTRACTOR AGREEMENT

I agree to serve as an independent contractor with respect to any assignment that I accept. Further, I agree to hold ODUA, the ODUA Board of Directors, and the Commissioner harmless and free from any and all liability for injury and damage sustained as a result of my assignments. I agree that I will attend the State officiating baseball clinic, work scrimmages, and take written examinations as required. I understand that all members of ODUA are independent contractors and accept assignments on their own volition. I understand that registration does not carry any obligation on the part of the Commissioner for a specific number of assignments. Any assignment that I receive is subject to cancellation by the Commissioner if he, or the majority of the ODUA Board of Directors, deems such cancellation to be in the best interest of ODUA. Further, I agree to hold the Commissioner and/or the ODUA Board of Directors, harmless with all respect to game assignments.

I have read and agree to the CONTRACTOR AGREEMENT.

COMPLIANCE WITH CODE OF VIRGINIA �22.1-296.1

I, the undersigned, under penalty of perjury, certify that I have never been convicted of a felony or any offense involving the sexual molestation or physical or sexual abuse or rape of a child.

I have read and verify that I comply with the COMPLIANCE WITH CODE OF VIRGINIA �22.1-296.1.

Old Dominion Umpires Association Umpire Registration Form