WISL, INC. REFEREE'S GAME REPORT

This report and both team rosters must be affixed together and mailed within 48 hours after completion of the match to:

Peter Accolla, 6401 Woodland Court, Clifton VA 22204 or Nader Nikhoo, 11824 Rockaway Lane, Fairfax, Virginia 22030

Game:   Score:   vs.   Score:  
  Home Team       Away Team    
Date:   Scheduled Kickoff:

AM/PM
Field:   Actual Kickoff:

AM/PM
If forfeit referees paid by                                                       Yes      No  End of game:

AM/PM
Referee   Score at halftime:  
Linesman # 1   Field condition:  
Linesman # 2   Weather:  
WISL passes of home team (were / were not) received and checked. Received full game fee?    Yes     or     No
WISL passes of visiting team (were / were not) received and checked. If forfeit was involved did forfeiting team make payment?
Official WISL Roster Form of home team (is / is not) enclosed. How much did forfeiting team pay?
Official WISL Roster Form of visiting team (is / is not) enclosed.  

(Use the reverse side of this form if additional space is needed to explain any unusual circumstances)

Serious injuries during the game:
     
Name Team Nature of Injury
     
Name Team Nature of Injury

Players cautioned during the game:
       
Name Team Type of Misconduct Two-Minute Rule Imposed? (Y/N)
       
Name Team Type of Misconduct Two-Minute Rule Imposed? (Y/N)
       
Name Team Type of Misconduct Two-Minute Rule Imposed? (Y/N)
       
Name Team Type of Misconduct Two-Minute Rule Imposed? (Y/N)

Players Sent Off the Field -- WISL pass must be retained after the game and returned to Peter Accolla with this report.
       
Name Team Type of Misconduct Add'l Circumstances - use other side if needed
       
Name Team Type of Misconduct Add'l Circumstances - use other side if needed
Referee Signature: