Player’s Name (print) : ………………….……………………..…………Date of Birth : ……..….……………..

Address : …………….……………………………………………………………………….………….……………….

Request Clearance from : ……………….…………………………RLFC in the following division/club/

district or group : …………………………………….

Year player last played : ………………to play with the: ………………………….………….Club in the

following division/club/district or group : ……………………….……in the state/Country of …….……

Player’s signature : ……………….…………………………….….……………Date : …………..……………….

Playing Details : Nominate player’s highest level in the last two seasons.

Senior : …………….…………………………………………………………………..…Year : ……….…………..

Junior : …………….…………………………………………………………………..…Year : ……….…………..

School : …………….…………………………………………………………………..…Year : ……….…………..

Name of Club/Group/State/Country :………………………………………………………………………….

 Authorised by (signature)………………………………………………………Date :…………………………..

Group and/or District : ………………………………………………………………..…………………………..

Division/Country League : ………………………………………………………………………………………..

State League : ………………………………………………………………………………………………………..

National League :…………………………………………………………………………………………………….

Development Fees on Clearance : $………+ GST…..  Amount due on NRL Debut : $……+GST….

Notes : ……………………………………………………………………………………………………………………

Special Conditions : …………….…………………………………………………………………..………........

…………………………………………………………………………………………………………………………..

Judiciary Report : ………………………………………………………………………………………………….

………………………………………………………………………………………………………………………….