Contact Information
Team Name:
Age Group (please circle one):
U14 U15 U16 U17 U19
First Name: Last Name:
Mailing Address:
City:
State/Region: Postal Code:
Country:
HM Phone: WK Phone:
Email Address: Club Web Site:
Team History
Please provide the complete 2002 results and standings of the league(s) in which you compete. Please provide on a separate one-page statement any additional information that may enable the committee to make its selection:
Please send application to one of the following:
USL
c/o Portugal 2004
14497 North Dale Mabry Hwy, Suite 201
Tampa, FL 33618
USA
PH: +011 813.963.3909
Fax: +001 813.963.3807
