Colorado Ice Hockey Referee Association Registration Form

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Submittal Instructions:
Fill out ALL fields on the Form by typing in your information.  (None of your information is saved or submitted
here - it is strictly to have typed, legible data on your Registration Form, for correct entry into our
Accounting/Payroll system)

Last Year Level:   Choose Last Years Level: None - New 1 2 3 4      Applied for Level:   Choose Applied for Level: 1 2 3 4

Your LAST Name:                                                   Your FIRST Name:
                
Your Street Address:

Your City:                                     Your State:                                    Your Zip:
             
Your Home Phone Number:      Your Work or Cell Number: 
        
Your Email Address:                                               Your Age: 
    
Your Social Security Number:
  ** Mandatory for officiating within CIHRA. 
(If you do not provide aValid SSN, EIN, or TIN, you will not be allowed to Officiate within CIHRA).

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Annual Membership Dues: 
Level ONE - $35.00     Level TWO - $45.00     Level THREE - $55.00     Level FOUR- $60.00

By Printing, Signing, and Submitting this Registration, you agree to be bound by CIHRA's operating Bylaws
and Code of Conduct.  If you do not agree,  you are unable to continue with your Registration process and join
CIHRA.

Print this Form now. 

Sign and mail with Dues payment to:     CIHRA, 2075 S University Blvd, #202, Denver, CO, 80210

Signature: __________________________________________________________________________