CVBOA
Central Virginia Basketball Officials Association
10301 Brightstone Dr.
Midlothian, Virginia 23112
804-639-0929 Office 888-849-1503 Fax

Registration Form 2016/2017

Name: ______Social Security#______

Address: ______Zip: ______

Email address: ______Years of Service (CVBOA) ______

Phone Numbers

Home: ______Work: ______Cell: ______

School Affiliations

List any schools that may present a conflict of interest.
______

CONTRACT AGREEMENT

I agree to serve as an Independent Contractor with respect to any assignment that I accept. Further, I agree to hold CVBOA, Inc., and its Commissioner harmless and free from any liability for injury and damage sustained as a result from my assignment. I understand and agree to complete the State Officiating basketball clinic and exam, and work the required number of scrimmages. I also agree to obtain the required accounts with Arbiter and Refpay.

I understand that registration does not carry any obligation, on the part of the Commissioner, for specific number of assignments. Any assignment, which I receive, is subject to cancellation by the Commissioner if he deems such cancellation to be in best interest of CVBOA, Inc.

CERTIFICATE OF COMPLIANCE WITH CODE OF VIRGINIA 22.1-296.1

I hereby certify that I have not been convicted of a felony or any offense

involving the sexual molestation or physical or sexual abuse or rape of a child; and that I have not been convicted of a crime of moral turpitude (lying or stealing).

I hereby agree, to the fullest extent permitted by applicable law, to indemnify and

hold harmless Central Virginia Basketball Officials Association Inc., VHSL Events LLC, a Virginia limited liability company, Virginia High School League, Inc., a Virginia nonstock corporation, and the members, managers, officers and directors of such entities (collectively, the “Indemnified Parties”) from, against and for any losses, costs, expenses, claims, demands, suits, judgments and all other liabilities (including attorney’s fees, expenses and court costs), to which the Indemnified Parties may be subject as a result of any false statement contained in thisCertification

Print Name:

Signature: ______Date: ______

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