Oregon Adult Soccer Association

Certificate of Insurance Request   

Do not abbreviate                                                   Certificate of Insurance Request Form

Team Name:

League Name:

Name of Field/Facility:

Address:

City/State/Zip:

Facility owner (City, school district, parks district, etc.)

Address of Facility Owner:

City/State/Zip:

Phone:

Facility owners representative:

(Name of the person able to grant permission to use field. Athletic director, parks employee, etc.)

Title of representative:

Fax to OASA 503.297.4513