<p> Coach’s Certification/License Application Affiliated with United States Soccer Federation (USSF)</p><p>Name: ______(First Name, Middle Name, Last Name, Maiden Name-if applicable)</p><p>Address: ______</p><p>City: ______State: ______Zip:______</p><p>Email: ______</p><p>Home Phone: ______Cell Phone: ______</p><p>Date of Birth: ______/______/______Sex: _____Male _____Female</p><p>Club Affiliation: ______</p><p>********************************************************************** Coaching Experience: ______</p><p>Existing License: □ Youth Module □ E License □ D License □ other______</p><p>Date Received: ______/______/______Location License was Received:______Instructor: ______</p><p>Present Field of Coaching (check type) □ Youth □ Adult □ Professional □ Non Active</p><p>Playing Experience: (highest level) □ Youth □ Amateur □ High School □ Professional</p><p>License Course Applying For: □ Youth Module □ E License □ D License</p><p>Location of Course: ______Instructor: ______</p><p>Make All Checks Payable to: SC Youth Soccer, 7436 Broad River Rd. Suite 211, Irmo, SC 29063 For Office Use Only: Payment Amount: ______Check/ Credit Card No.______</p><p>Received on: ______/______/______License Mailed: ______/______/______</p><p>(No cash payments accepted for registration)</p>