World University Championship
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2014 World University Taekwondo Championship
8 – 14 June 2014 Hohot, China
Nomination Form Part 1- Kyorugi and/or Poomsae International Referee
Due to the tight time frames this form must be returned to STA via email to: [email protected] on or before 5pm 21 March 2014 for consideration
SURNAME ...... FIRST NAME......
HOME ADDRESS ...... …………..……………………………….. P/C……………….
WORK ADDRESS ...... …………………………………….. P/C………….……
TEL: {H}:( ) ...... …….. {W}:( ) .....……...... {Mobile}: ......
Email Address: ...... ………......
If overseas for a period leading up to the event, please provide your contact details whilst overseas:
Date of Birth: ...... ……...
Place of Birth: ...... Nationality: ......
Passport Number: ...... Passport Expiry Date: ...... ……....
MNA Membership and Accreditation(s)
Nominated Position (Circle as many as required): Kyorugi IR / Poomsae IR / Both
Kyorugi – IR Number: ...... IR Class: ...... 2014 WTF IR Dues paid (Y / N)
Date and Place of last WTF IR Kyorugi Seminar attended: ......
Poomsae – IR Number: ...... IR Class: ...... 2014 WTF IR Dues paid (Y / N)
Date and Place of last WTF IR Poomsae Seminar attended: ......
2014 STA Membership Number: ……………………………………………….
I declare the above particulars to be true in every respect.
Signed (Applicant) ………………………………………………… (Date) …………………………….
Please complete Nomination Form Part 2 (next page) WORLD UNIVERSITY CHAMPIONSHIPS – Hohot, China 2014
Nomination Form Part 2: Kyorugi and Poomsae Referee History
Name: ...... ………......
International Referee Experience at WTF Sanctioned Events: Please include events and year of competition and indicate Kyorugi and / or Poomsae ......
Domestic Referee Experience at STA Sanctioned Events and non Sanctioned international events: Please include events and year of competition and indicate Kyorugi and / or Poomsae ......
Please briefly explain your understanding and involvement with University Sport both domestically and internationally......
Have you previously travelled to China? (If yes, when, where and in what capacity?) ......
Additional information (Relevant qualifications, accreditation's, etc) ......
Please attach any further relevant documentation.
I hereby certify that I have included a true and correct record of my coaching and management experience. I understand and accept the financial and time commitments associated with this tour.
Signed ...... …... Date ...... ……..
PLEASE NOTE: STA will work with Australian University Sport in the nomination and preparation of the team for the Championships. Only those who submit an expression of interest may be considered for selection.
This form must be returned by 21 March 2014 to: Rene Leveaux, Director University Taekwondo, Sports Taekwondo Australia [email protected]