Prescribed Form 07

WRITTEN STATEMENT BY PARTICIPANT
CHALLENGING A DECISION ON THE BASIS
OF MISTAKEN IDENTITY IN A MATCH OFFICIAL
INCIDENT REPORT (SECTION 7.3)
Prescribed Form 07

Your Details

Full Name*

First NameLast Name

FFA Number*

Club Name*

Match Details

Opposition Team*

League*

Grade*

Date & Kick off time*

MonthDayYearHourMinutesAM/PM Option

Submission

1. I declare that the following Participant of my Club was responsible for the Offence and the Suspension issued against me should be transferred across to the Participant mentioned below:

Participant 's Name

First NameLast Name

2. I declare that the information in this statement is accurate and to the best of my knowledge.

3. I acknowledge that I may be charged with Misconduct if it is established that the contents of this statement are incorrect and amount to an abuse of process.

Notes:

1. Please submit this form by 4pm the next working day after the issuance of the notification of the Incident Report to the Club by the CDSFA.

2. In addition to submitting this form, please submit the following documents at the same time:

a. Prescribed Form 08 by the Participant actually responsible for the Offence OR a Prescribed Form 09 by your Club identifying the Participant responsible for the Offence; and

b. Any other evidence which may support your challenge.

3. Participants should read and consider section 7.3 prior to signing and lodging this form with the Disciplinary Tribunal.

4. If the CDSFA does not receive properly completed forms by the time specified in paragraph 1, you are deemed to have committed the Offence and will be issued with a Notice of Suspension.

5. Capitalised words used in this document are defined in the Regulations.

Submitter Details

Your name*

First NameLast Name

Your E-mail*

A copy of your submission will be emailed to this address.

Digital Signature*

I certify that the information entered above is true and correct and was entered by myself.

Submission Date*

DayMonthYear