GSLAU Join

2010 Application for Membership
Complete the following then click the SUBMIT button
You are required to mail your dues to:

Greater St. Louis Association of Umpires
8 Nordell Court
Florissant, MO 63033

Name Spouse Date

Address City, State & Zip

Home Phone Work Phone Cell Phone

Job Title Years with current employer

Email Address Fax Number

Disclosure/Authorization Form

NOTICE TO APPLICANT REGARDING BACKGROUND CHECK
In order to safeguard the youth and adults for whom we provide services, the Association may procure criminal, consumer, and sex offense reports on you in connection with your application and may procure additional such reports at any time during your service in order to evaluate your continued suitability for service. If such a report is procured, you will be advised of the identity of the reporting agency, and given its contact information. The reports may contain information bearing on your character, general reputation, and personal characteristics. The types of information that may be obtained include but are not limited to Social Security number verification, sex offender registry checks, criminal records checks, inmate records searches, and court records checks. The information contained in these reports may be obtained from public record sources. The reports will not include credit record checks. You are entitled to request a complete and accurate disclosure of the nature and scope of such reports by submitting a written request to any credit reporting agency

APPLICANT’S ACKNOWLEDGMENT AND AUTHORIZATION
Your signature to this Application constitutes your authority to the Association to procure the types of reports set out above, which relate to any criminal history, employment history, and allegations of the type of misconduct that may render you unsuitable to act on behalf of the Association. Your signature acknowledges that you understand this information will be used to determine your current and continued eligibility for service as a sports official under the auspices of the Association. If the Association chooses not to accept this Application or to terminate your services on information contained in a consumer report, you will receive a summary of our rights under the Fair Credit Reporting Act and contact information for the reporting agency.

The following answers must be provided to enable us to consider this Application:

1. Have you ever been charged with, arrested for, or accused of misconduct or a crime based upon use of alcohol,
drugs, controlled substances, or the internet, or pertaining to pornography, adult abuse,
molestation, sexual or moral misbehavior? Yes No

If your answer to the last question was "yes", check the disposition of that matter as follows:
matter dropped/dismissed; conviction; suspended sentence;
guilty plea not resulting in a conviction; other

What is the name and location of the agency, court or police department involved:

2. Have you ever been disciplined, or terminated from employment or a business relationship, alleging it is for
commission of a felony, or use of alcohol, drugs, controlled substances, or pertaining to pornography, adult abuse,
molestation, sexual or moral misbehavior? Yes No

If so, what were the circumstances:

and: What is the name and location of the agency, employer or person taking that action:

3. List all prior names and variations of your legal name, by which you have been known publicly in the last five (5) years,
other than nicknames or as used by relatives and friends:

If you have changed your legal name at any time, please state the reason:

BASEBALL: Spring Summer SOFTBALL: Summer Fall

This is my year as a member of the GSLAU - Assigned Shirt No.

Social Security Number (required) State Registration No.

What time can you leave work? AM PM

Nearest MAJOR INTERSECTION from where you leave for a game

NEW MEMBERS ONLY

Years experience umpiring Baseball Softball Both

How did you hear about us? Ad Member School or Other

Do you need equipment? Yes No

Are you currently registered with the MSHSAA? Yes No
If so, what is your registration number?

Any question about this application call Mike Behnen 314-650-6935 (Cellular)
Remit $30.00 dues after submitting this application to the address above.
New applicants add a one-time $15.00 initiation fee.

Any further dues will be deducted from spring game fees.
In making this application, I agree to be bound by the By-Laws and
Rules & Regulations of the Greater St. Louis Association of Umpires.