Coach’s Certification/License Application Affiliated with United States Soccer Federation (USSF)

Name: ______(First Name, Middle Name, Last Name, Maiden Name-if applicable)

Address: ______

City: ______State: ______Zip:______

Email: ______

Home Phone: ______Cell Phone: ______

Date of Birth: ______/______/______Sex: _____Male _____Female

Club Affiliation: ______

********************************************************************** Coaching Experience: ______

Existing License: □ Youth Module □ E License □ D License □ other______

Date Received: ______/______/______Location License was Received:______Instructor: ______

Present Field of Coaching (check type) □ Youth □ Adult □ Professional □ Non Active

Playing Experience: (highest level) □ Youth □ Amateur □ High School □ Professional

License Course Applying For: □ Youth Module □ E License □ D License

Location of Course: ______Instructor: ______

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.______

Received on: ______/______/______License Mailed: ______/______/______

(No cash payments accepted for registration)