Prescribed Form 05

WRITTEN STATEMENT BY ACTUAL PARTICIPANT
COMMITTING THE RED CARD OFFENCE -
MISTAKEN IDENTITY IN A MATCH OFFICIAL
SEND-OFF REPORT (SECTION 7.3)
Prescribed Form 05

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 I participated in the above Fixture.

2. I declare that I was responsible for the Red Card Offence issued against the Participant referred to below:

Participant 's Name*

First NameLast Name

3. I consent to being issued with a Notice of Suspension instead of the Participant referred to in paragraph 2 above.

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

5. I acknowledge that I may be charged with Misconduct if it is established that 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 completion of the match.

2. Participants MUST submit Prescribed Form 04 at the same time as submitting this Form.

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

4. If the CDSFA does not receive properly completed forms by the time specified in paragraph 1, the Participant issued with the Notice of Suspension shall serve the 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