United States Soccer Federation, Inc.
International Clearance Form
Request Form
Form ITC-4/02
MALE 
FEMALE 
A. BIOGRAPHICAL INFORMATION
(Type or print clearly)

Player's Last Name First Name Middle Initial
Mother's Maiden Name First Name Middle Initial
Father's Last Name First Name Middle Initial
Current United States Address City State Zip

Date of Birth Social Security Number
/ /   / /    
Month Day Year   (optional)   Place of Birth (City & State)   Country

Citizenship Contact Number in the United States

B. REQUEST FOR INTERNATIONAL TRANSFER CERTIFICATE

Last Foreign Club Participated League State/Country
ASAP
Date of Last Game Professional/Amateur Date Clearance Requested
Southern Illinois Adult Soccer League Illinois/USA
Club Wishing to Participate With League State/Country

I hereby confirm all of the above information to be correct. I also confirm that I am presently not under a professional contract to any other team (domestic or foreign) and I am not under suspension by any member organization ofFederation Internationale de Football Association.
Signature of Player Date
Signature of Parent or Guardian (if applicable) Date
Please complete and submit this form either by fax or mail to:
Illinois State Soccer Association
2001 S. Halsted Street, Suite 100
Chicago, IL 60608
T: 312-226-7920
F: 312-226-0722