Citing Referral Form

This form must be completed and submitted by 12.00 p.m. on the first business day following the match. For regular season matches this will be 12.00 p.m. on the Monday. All relevant information must be supplied at the time of submission of this form or it may not be considered by the Citing Commissioner.

Extension of Time

An extension of time must be applied for within the original citing window (i.e. prior to 12.00 p.m. on the Monday following the match).

Are you applying for an extension of time? *

YesNo

Reason for Extension of Time

Citing Referral Information

Referring Team / Rugby Body / Union *

Nominated Official Name *

Nominated Official Email *This email address will be used to send a copy of the completed form in PDF format and to inform the nominated official of the outcome of the Citing Referral.

Match *

Match Venue *

Date and Time of Incident *

Name of Alleged Offending Player (if known)

Team of Offending Player *

Playing Position of Player

Jersey Number Worn *

Foul Play Alleged *

Incident Description (include the time of the incident in the match): *As you type into this field it will expand to allow you to enter more information.

Name of alleged victim player(s): *

Injuries Sustained (if any):

Witness Details

Name

Role

Contact Details (if known)

Was the alleged act of foul play detected by Match Officials? *

Please detail the actions taken:

Please detail any other relevant information below:Include here any links to video footage if it is too large to upload to this form.

Relevant Materials (Including Video):

Browse

I confirm that the details provided are true and correct to the best of my knowledge. *

Draw signature|Type signatureClear

Name *

Date Submitted

Payment Details

A Citing Referral Deposit Fee of $250.00 must be paid prior to the closure of the citing window.

There are two ways to pay this fee - either by bank transfer or via credit card payment. When you select your preferred method of payment you will be provided further instructions.

If the Citing Referral is upheld or a Citing Commissioner's Warning is issued then $200 of the deposit will be refunded. If the Citing Referral is dismissed then the entire deposit amount will be forfeited.

Please select your method of payment *

Bank TransferCredit Card Payment

A citing deposit of $250.00 must be paid into the following account:

BSB	013-423
Account Number	253207325
Account Name	Victorian Rugby Union Inc

DO NOT MAKE PAYMENT BY CREDIT CARD UNTIL YOU HAVE COMPLETED ALL THE REQUIRED INFORMATION AS CLICKING 'PAY AND SUBMIT' WILL SUBMIT THE FORM IMMEDIATELY AS WELL AS MAKING PAYMENT.

Citing Referral Deposit

Pay

Please do not pay until you have completed all of the required information in the Citing Referral Form as clicking the 'Pay' button will submit the form as well as making payment.