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 30 days will be refused.

A form must be mailed for each and every record that you break.

First Name- ______________________   Last Name-_______________________

Email-_______________________________  Phone:(_____) ________________

Wt. Class-____  Date of Record-______  Name of Meet-____________________ Division-__________

Meet Director-______________________  Were you Drug Tested-  Yes    NO

Type of Record Broken (please circle) -   State     American     World

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

__ Power Sports   __ Powerlifting   __Equipped BP   __Unequipped BP

 __Unequipped Powerlifting   __Push Pull

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

Curl__   Squat__   Bench Press__   Deadlift__  Total__

Total Kgs lifted for this Record-______kgs

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 30 days of the meet to:

NASA Records Chairman, P. O. Box 735 , Noble , OK . 73068

Do not send State Records to this address! They will be null and void!