UNITED STATES FUTSAL
NATIONAL CHAMPIONSHIP XVI

2001 FUTSAL CHAMPIONSHIP XVI APPLICATION
March 23 - 25, 2001 -- Las Vegas, Nevada

NAME OF STATE / NAT. ASSN:
NAME OF TEAM:
AGE CATEGORY:
NAME OF COACH/MANAGER:
ADDRESS & PHONE #:

PLAYERS NAME

DOB

JERSEY #

REGISTRATION #

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

I hereby certify that the above information is true and correct, and that I have read and understand the rules.

Manager Signature:________________________________________Date:___________

PLAYERS NAME	DOB	JERSEY #	REGISTRATION #
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.