SFA-C01 FORM

PERSATUAN FLOORBALL
NEGERI SELANGOR
(No. Ruj. 7052/2014)

Ref. no:

SFA-C01

Register Status

CLUB REGISTRATION FORM

New

Year:

On time

Late 1

Late 2

CLUB INFORMATION
Club name:
Affiliates
(school/university/company) :

Club colors:

No. of club members :

Date establish :

Category:
( MALE / FEMALE / MIX)

Level : ( SCHOOLS / VARSITY / OPEN )

Mailing Address:
Manager full name:

Assistant manager full name:

Manager mobile phone no.:

Club / Manager e-mail address :

Manager NRIC or passport no.:

Nationality :

Assistant manager mobile phone no.:

Assistant manager NRIC or passport no.:

Nationality :
Coach full name:

Coach mobile phone no.:

Coach e-mail address :

Coach NRIC or passport no.:

Nationality :

CLUB DECLARATION
I, (manager full name)

, (NRIC or Passport no)

As the manager of the club as stated above, declare on behalf of the club that:

All information provided in form SFA-C01 & SFA-C01A is true and complete to the best of my knowledge and belief.
I undertake that, if admitted as a registered club of Selangor Floorball Association (SFA), the club and all the
registered players attached to the club shall be bound by the SFA constitution, bylaws, policy and rules made there
under.
I undertake that, SFA, the committee members and relevant associate party of SFA will not be hold responsible for any
unforeseen incidents or mishaps that may occur to all registered players attached to the club while participating in any
events of SFA or SFA endorsed events.

(Manager signature) :

(Date) (DD/MM/YY) :

(Payment amount) :

For SFA use only

Register Status Checklist

CLUB FEE

RM

Within transfer window

Early registration 0

RM 150

CLUB PENALTY

RM

Transfer window

New registration 00

RM 100

GRAND TOTAL

RM

New club

[Y/N]

Late registration 1

RM 200

RECEIPT NO

Returning club

[Y/N]

Late registration 2

RM 250

DATE

Recurring club

[Y/N]

SIGNATURE

Last Register Year

[Y/N]
[ 0 / 00 / 1 / 2 ]

[PRESIDENT]

Approve / Reject

SIGNATURE
[HON. SECRETARY]

Total player forms submitted

pieces

Total player registered

pax

Total late registered player

pax

Address: No. 24, Jalan 10/3, Taman Putra, 68000 Ampang, Selangor Darul Ehsan

Date:

Reason of rejection :

Contact: +6 017 237 3940

Email: selangorfloorball@yahoo.com