Columbus Premier Soccer League
502920-39370005378450005391150006108702921000COLUMBUS PREMIER SOCCER LEAGUEREFEREE ASSESSMENT FEE REIMBURSEMENT REQUESTMatch: vs. (home club)(away club)Referee Name: Date of Match: Referee Role (check one): Center AR1 AR2Time of Match: Assessor Name: Cooper Field #: Assessment Fee Paid: $Method of Reimbursement (check one): Check by Mail Address: City: State: Zip: - or - PayPal PayPal Account Email Address or Phone Number: send via regular mail:Columbus Premier Soccer LeaguePO Box 09866Columbus, Ohio 43209- or -send via email:columbuspremierleague@ Note: Reimbursement requests must be received by the Columbus Premier League within thirty (30) days from date of Assessment-----------------------------------------------------------------------------------------------------------------------------For CPSL Office Use OnlyDate Received: Assessor Certification Date: Date Reimbursement Sent: Completed by: ................
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