NASA American and World Record Application

All Records Must be submitted within 30 days of the date of the meet to be valid. Any Record Application received after 15 days will be refused. These forms MUST be filled out COMPLETELY. ANY blank sections will result in the record form being discarded.

NOTE: A separate form MUST be used for each and every record that you break. One Record Per Form!

Please PRINT Legibly

First Name- ______________________   Last Name-________________________ Date of Record-______________ 

Email-__________________________________________   Phone :(_____) ________________        Age:______

Wt. Class-_______     Name of Meet Where Record was broken -________________________________________________

Meet Director-_______________________________          Were you Drug Tested-     Yes        NO

Check One –    ____ Male Lifter         ____ Female  Lifter

Type of Record Broken (please indicate) -    _____ American       _____ World  (Only at National Events)

Division you were entered in when Record was set?  You MUST be entered in that division. Please Circle the Division.

Pure – Open – Novice – Police, Fire & Military – Teenage – High School – Junior – Intermediate – Sub Masters 1 –

             Sub Masters 2 – Sub Masters Pure – Masters 1 – Masters 2 – Masters 3 – Masters 4 – Masters Pure (5)

My Record was set in the following portion of the meet (check one):

__ Power Sports (no equipment)      __ Powerlifting Equipped       __Equipped BP       __Unequipped BP (not Power Sports)

__Unequipped Powerlifting       __Push Pull (Equipped Only)

I broke this Record in the following lift (check one):

Curl______         Squat______          Bench Press______        Deadlift  ______      Total_______

Total Kgs lifted for this Record-________kgs     (This MUST be in Kilo’s or this record is Invalid)

I certify that the above information is true and accurate. I realize that if this information is not true and accurate the record I am applying for will be forfeited. I also realize that I have a maximum of 30 days from the date of the meet to submit this application to the appropriate Records Chairperson. I also understand that if this application is not received within 30 days my record will become null and void, no exceptions. I also understand that I must submit one single application PER record broken.    Signed-______________________________________   Date-_________________

American & World Records ONLY:

If you choose to Print and Mail this form, please return within 15 days of the meet to:

Clyde Lynn - NASA Records Chairman, 6006  85th Street, Lubbock, TX  79424  
or 
Email to:  RecordChairman@rocketmail.com    

Do not send State Records to this address! They will be null and void! Send State Records to your State Record Chairman.