Club Rep / Scout Registration Form

Please complete the form below to register your interest for Progression 2012 - The Assessment Trials, in conjunction with The PFA and The Football League.

Entry to all Club Representatives/Scouts is free and refreshments will be provided. A full programme and player profiles will be made available on the day.

Information on those players who have registered an interest to play are listed at: www.lfe.org.uk

Your Contact Details

First name / Surname

  *

Telephone

*

Mobile

*

Fax

Email address

*

Confirm email address

*

Your Postal Address

House / Street

*

Town / City

*

County

Please select Outside UK Aberdeenshire Anglesey Angus Argyll & Bute Avon Ayrshire Banffshire Bedfordshire Berkshire Berwickshire Birmingham Blaenau Gwent Bridgend Buckinghamshire Caerphilly Caithness Cambridgeshire Cardiff Carmarthenshire Ceredigion Cheshire Clackmannanshire Cleveland Clwyd Conwy Cornwall County Antrim County Armagh County Down County Dublin County Durham County Fermanagh County Limerick County Londonderry County Tyrone Cumbria Denbighshire Derbyshire Devon Dorset Dumfries and Galloway Dunbartonshire Dyfed East Ayrshire East Dunbartonshire East Lothian East Renfrewshire East Sussex Edinburgh Eilean Siar Essex Falkirk Fife Flintshire Glamorgan Glasgow Gloucestershire Greater London Greater Manchester Gwynedd Hampshire Herefordshire Hertfordshire Highland Humberside Inverclyde Invernessshire Isle of Wight Kent Lanarkshire Lancashire Leicestershire Lincolnshire London Merseyside Merthyr Tydfil Mid Glamorgan Middlesex Midlothian Monmouthshire Moray Neath Port Talbot Newport Norfolk North Ayrshire North Lanarkshire North Yorkshire Northamptonshire Northumberland Nottinghamshire Orkney Islands Outside UK Outside UK Oxfordshire Pembrokeshire Perth & Kinross Powys Renfrewshire Rhondda Cynon Taff Ross-shire Scottish Borders Shetland Shropshire Somerset South Ayrshire South Glamorgan South Lanarkshire South Yorkshire Staffordshire Stirling Suffolk Surrey Sutherland Swansea Torfaen Tyne and Wear Warwickshire West Dunbartonshire West Lothian West Midlands West Sussex West Yorkshire Wigtownshire Wiltshire Worcestershire Wrexham Yorkshire *

Country

Please select United Kingdom Canada Ireland United States Austria Belgium Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Slovakia Slovenia Spain Sweden Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El salvador Equatorial Guinea Eritrea Ethiopia Falkland Islands Faroe Islands Fiji French Guiana French Polynesia Gabon Gambia Georgia Ghana Gibraltar Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Israel Jamaica Japan Jersey Kazakstan Kenya Kiribati Kuwait Kyrgystan Lao Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Macau Macedonia (FYR) Madagascar Malawi Malaysia Maldives Mali Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Solomon Islands Somalia South Africa South Georgia South Korea Sri Lanka Sudan Suriname Swaziland Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates Uruguay US Minor Outlying Islands Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe *

Post code

*

Your Football Details

Club/Organisation Name

*

Position held

*

Please indicate which Assessment Trials you would like to attend:

North Region

No Yes

Hyde FC (Manchester) Thursday 3rd May 2012 (6pm - 9pm)

South Region

No Yes

Staines Town FC (West London) Tuesday 8th May 2012 (6pm - 9pm)

Midlands Region 1

No Yes

Walsall FC (West Midlands) Wednesday 9th May 2012 (6pm - 9pm)

Midlands Region 2

No Yes

Loughborough University (East Midlands) Thursday 10th May 2012 (6pm - 9pm)

NB: Please note that the first kick-off is at 6pm. You will be asked to arrive prior to this time.