Umpires Course and Exam Application Form

Umpires Course and Exam Application Form
The attached Application form may be used by those wishing to apply to take the
course and examination to become a newly qualified Club Umpire.
It may also be used by existing umpires wishing to further their careers by upgrading
to a higher grade (County/National) Umpire.
Whatever you are applying to achieve may I, on behalf of the EPA Umpires
Commission, wish you every success in your endeavours.
Please read the following notes below before completing the application:
•
Please use Block Capitals to complete the form
•
Select the training level required, and enclose the correct payment.
•
ALL applications must be endorsed on page two.
Please ensure this page is completed by the relevant person before returning
the application form
•
Upgrade candidates MUST provide a list of duties performed at their current
grade.
•
Please complete the Voluntary Disclosure form on page three.
Robert Parker
Chair - Umpires Commission
Umpires Course and Exam Application Form
APPLICANT DETAILS (Please complete in BLOCK CAPITALS)
Full Name:
Mr/Mrs/Miss/Ms
Address:
Date of Birth:
D D /
M M
/ 19
Telephone No.:
Post Code:
Mobile No.
Email Address:
Please state any disabilities: (The EPA does not discriminate against age or disability)
Club
Region
TRAINING LEVEL (please select the training level required)
Application for initial training as CLUB Umpire (2 years playing experience required)
£25
Application for upgrade to COUNTY Umpire (2 years experience as Club Umpire required)
£20
Application for upgrade to NATIONAL Umpire (2 years experience as County Umpire required)
£20
All applications should be endorsed on page two.
Upgrade applications should be accompanied by a list of duties carried out at current grade
Signature
Date
Please post both pages of completed application form and the Voluntary Disclosure form together with
cheque for the correct amount made payable to English Pétanque Association:
Mr R. Parker, Chair – Umpires Commission
90 London Road, Rayleigh, Essex, SS6 9LD
OFFICIAL USE ONLY
Candidate Number
Candidate Region
Course
Date
D D /
M M
/ 20
Comments
D D /
M M
/ 20
Result
Venue
Tutors Signature
Examination
Date
Venue
Pass 
Fail 
Examiners Signature
Qualification
Certificate Expiry
Re-Assessment
D D /
1 year
M M

/ 20
4 Year

Grade
Club Umpire

National Umpire 
County Umpire 
%
ENDORSEMENTS
Club Umpire (Endorsed by your Club Umpire & Chairman or Secretary)
In our opinion, the applicant is suitable to become a Club Umpire and has at least two years experience as a player.
Name
1
Address
Name of Club
Office held in Club
Signed
Tel. No.
Name
Address
Signed
Tel. No.
2
County Umpire (Endorsed by your Regional Umpire & Regional President or Secretary)
In our opinion, the applicant is suitable to become a County Umpire and has at least two years experience as a
Club Umpire.
Name
1
Address
Name of Club
Office held in Club
2
Signed
Tel. No.
Name
Address
Name of Club
Office held in Club
Signed
Tel. No.
National Umpire (Endorsed by your Regional Umpire & President or Secretary)
In our opinion, the person above is suitable to upgrade to National Umpire and has at least two years experience as a
County Umpire.
Name
Name
Office held in
Region
Comments (continue on separate sheet)
Office held in
Region
Comments (continue on separate sheet)
Signed
Signed
Voluntary Disclosure Declaration
In order to comply with the requirements of the Children & Vulnerable Adults legislation, please complete the
following Voluntary Disclosure:
Do you currently have a valid DBS certificate?
If Yes, please provide:
Yes / No
If “no” please complete the section below
Disclosure Certificate Number :
Date of Issue :
Issuing (Umbrella) Body to DBS:
Post for which DBS Issued for:
Have you any previous experience in working with Children and/or Vulnerable Adults?
Yes / No
If Yes, please describe
Have you ever been convicted of a criminal offence, or been the subject of
a Caution or Bind Over Order?
Yes / No
If Yes, please state the nature & date(s) or the offence(s)
Have you ever been subject to any disciplinary action or sanctions relating
to the abuse of children or other vulnerable people, eg disabled?
Yes / No
If Yes, please give details
You are required to self certify, by signing below, that you are not known to ANY Social Services Department as
being an actual or potential risk to children & that you have not been disqualified or prohibited from having contact
with children & the vulnerable. We reserve the right to refer your details for verification to the Criminal Records
Bureau / Police / Social Services
Signature
Date