Application for Official’s Re-accreditation
Name: Dr / Mr / Mrs / Miss / Ms Address:
State: P/code:
Phone No: (home) (work) (mob)
Email Address:
Member Number:
D.O.B.: __ __/ __ __/ __ __ Gender: M / F
Please tick each of the activities you have completed in the four years 20 __ __ to 20 __ __
These activities are compulsory
Performance in position(s) has been assessed by a peer for at least 4 hours
Name of assessor Signature of assessor
Attended all seminars on Procedure or Rule changes; or
Have completed email assignment on Procedure or Rule changes
I wish to apply for re-accreditation as a ………..
[Print title of position. If more than one position you will need a new form for each of the positions]
Signature of applicant: Date: __ __/ __ __/ __ __
Verification: I confirm that the activities listed above have been completed by the official over the last four years
Name: ____________
(Branch Technical Officer or deputy).
Signed:_______
Position:
Date: __ __/ __ __/ __ __
Branch Office Use Only
Entered on Re-accreditation List and forwarded
to National Office for entry on National database Signed:
Date: __ __/ __ __/ __ __
MSA Technical Course Modules – Support Material Application for Official’s Reaccreditation
August 2 2009 – No part shall be reproduced without the permission of MSA
Masters Swimming Australia Inc Sports House, Level 2, 375 Albert Road Albert Park VIC 3206
