Club submitting this report *
Name of person submitting report *
Home phone #
Work phone #
E-mail address *

Match date  *
Match venue *
Home team name *
Visiting team name *
Scheduled kick-off time         Actual kick-off time

Referee name  *
Touch judges names  

FINAL MATCH RESULT:  Home Team Score *        Visiting Team Score *
Half-time score: Home Team  *       Visiting team *
Number of tries Home Team  *       Number of tries Visiting Team *
Please note below the names, method of scoring, and points scored by each of your players in this match.

Was the field marked properly?   Yes No
Were proper field flags installed?   Yes No
Were proper goal posts pads installed?   Yes No
Were proper 5 m barriers installed?   Yes No

GAME DAY ELIGIBILITY PROCEDURES

Player Eligibility
> Did your club download the opposition's current CIPP roster?  -- Yes No *
> Did you compare the opposition's match roster with their CIPP roster?  -- Yes No *
> Were there any discrepancies between the match and CIPP rosters?  -- No Yes *
> If you answered "Yes" to the above question, please list the names of the players in question.

> Did your clubs conduct a photo ID check before the start of the match?  -- Yes No

Club Matches Only
Did you check any players for citizenship status?  -- Yes No Not Applicable

Collegiate Matches Only
Did both teams present a completed Collegiate Eligibility Form?  -- Yes No
Did any players participate who were not on the Collegiate Eligibility Form?  -- No Yes
List the names of any players from the opposing team that you believe may be ineligible.

List your Match Roster - Last name, First name

#1   *
#2   *
#3   *
#4   *
#5   *
#6   *
#7   *
#8   *
#9   *
#10 *
#11 *
#12 *
#13 *
#14 *
#15 *
#16   Replaced #
#17   Replaced #
#18   Replaced #
#19   Replaced #
#20   Replaced #
#21   Replaced #
#22   Replaced #