NASA State 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
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-_________________
State Records ONLY:
If you choose to Print and Mail this form, please return within 30 days of the meet to:
Stephanie Gibson,
NASA Records Chairman,
Do not send American and World Records to this address! They will be null and void!