Player's Name:          
School Name:      
Player's Primary Position:       Keeper Defender Midfielder Forward    
Player's Secondary Position:  None Keeper Defender Midfielder Forward

Player's Address:   
City:                                     
State:                   North Carolina South Carolina Virginia Tennessee                                        
Zip Code:                
                                          
School Address: 
City:                   
State:                  North Carolina
Zip Code:            

Player's Phone Numbers:                                                       
Home:                                             
Cell:                                                

Player's E-mail Address:
Primary:     
Secondary: 

Player's Honors & Statistics:
 

Head Coach's Name:                
Head Coach's Home Address: 
City:                                          
State:                                       North Carolina South Carolina Virginia Tennessee
Zip Code:                               

Head Coach's Phone Numbers:                             
Home:                            
Work: 
Cell:    

Head Coach's E-mail Address:
Primary:      
Secondary: 

I hereby certify the following with my signature below:

1)  The player nominated above is a current senior and will graduate at the end of the spring semester this school year.
2)  The player nominated above will demonstrate good moral character on & off the field in representing NC and our school.
3)  In my opinion, the player nominated above is one of the top 18 players in the state of NC.
4)  If the player nominated above is chosen, it is my responsibility to make sure the player is ready and will show up for this event.

    Head Coach's Signature:  
 

By pressing the SUBMIT button, a copy of this will be sent to Mark Kadlecik by e-mail.

PLEASE NOTIFY YOUR REGIONAL CHAIRMAN OF WHO YOU ARE NOMINATING.