PENNSBURY SCHOOL DISTRICT CONTRACT FOR ATHLETIC OFFICIALS

The PENNSBURY SCHOOL DISTRICT, a member of the P.I.A.A. and

JOSEPH KENNEDY, an active P.I.A.A. registered official, in good standing,
hereby enter into the following agreement:
The official agrees to be present at and officiate a game of
GIRLS VARSITY BASKETBALL to be played at:

PENNSBURY HIGH SCHOOL EAST CHARLES BOEHM MIDDLE SCHOOL

705 Hood Blvd., Fairless Hills, PA 19030 866 Big Oak Road, Yardley, PA 19067
(215) 949-6863 (215) 428-4220

MACCLESFIELD PARK PENNWOOD MIDDLE SCHOOL

River Road Makefield & Roelofs Roads. Yardley, PA 19067
Yardley, PA 19067 (215) 428-4237

PENNSBURY HIGH SCHOOL WEST WILLIAM PENN MIDDLE SCHOOL

608 South Olds Blvd., Fairless Hills, PA 19030 1524 Derbyshire Road, Yardley, PA 19067
(215) 215-949-6759 (215) 428-4280

OTHER LOCATION:      

DATE 1/30/17 TIME 5PM POSITION UMP #2 FEE $ 71.00

PAYMENT WILL NOT BE PROCESSED UNLESS CONTRACT IS SIGNED AND RETURNED TO:
Pennsbury High School Athletic Office  608 South Olds Boulevard  Fairless Hills, PA 19030
OR FAX to (215) 949-6677 Phone (215) 949-6863 Email: DFallacaro@pennsburysd.org

Lisa Becker Louis Sudholz

Lisa Becker, Principal Louis Sudholz, Athletic Director

Under penalties of perjury, I certify that:

1. The number on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup holding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the
Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends,
or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to
backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions,
item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt,
contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not
required to sign the Certification, but you must provide your correct TIN.

________________________________________________ ________________________________________________
Street Address (Please Print Clearly) Phone #

________________________________________________ ________________________________________________
City, State and Zip Social Security #

__________________________________________________
Official's Signature

NOTE: ALL officials must have a Child Abuse Clearance, PA Criminal History Record, and Federal
FBI Criminal History on file with the Athletic Office BEFORE officiating any Pennsbury sporting
event. Failure to do so will result in removal from the event and forfeiture of officiating fees.