This form and all supporting information should be faxed to:
PSAL
44-36 Vernon Boulevard, 4th Floor,
Long Island City, NY 11101.
Attention: Alan Blanc,
Fax # 718-707-4224
Case #
(PSAL ELIGIBILITY FORM A)
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Submitted By
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________________________
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_________________________
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_________________________
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Name
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Title
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Date
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Name Of Student
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__________________________________________________________________
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OSIS
Number
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__________________________________________________________________
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Sport
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__________________________________________________________________
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School
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__________________________________________________________________
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Athletic Director
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__________________________________________________________________
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Principal
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__________________________________________________________________
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Coach
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__________________________________________________________________
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Contact Info (phone/e-mail/Fax #)
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__________________________________________________________________
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Please provide a brief description of the nature of the review. Attach a copy of
the student's transcript and any other pertinent documentation.
Top of Form
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Principal's Signature
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_________________________________________
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Coach's Signature
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_________________________________________
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Athletic Director's Signature
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_________________________________________
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Parent's Signature
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_________________________________________
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FOR COMMITTEE USE ONLY:
Date Name
Approved
Denied
Details