SPF / WBPLA RECORD APPLICATION FORM

 

If you would like to order a Certificate for the State, National or World Title that you hold, just fill out this form

and mail it and $7.00 per Certificate to : Jesse Rodgers   7493 Tanya Dr.   Harrison,  Tn.   37341 

 

NAME _____________________________________ DATE OF BIRTH ____________PHONE _____________________

 

MAILING ADDRESS: ________________________________________________________________________________

 

CITY: ________________________________________ STATE: ________________

 

POSTAL OR ZIP CODE: ____________________________  CONTEST WEIGHT: _______________

 

 DATE & PLACE YOU SET RECORD: ___________________________________________________________________

 

NAME OF THE CONTEST THAT YOU WERE IN: ___________________________________________________________

 

CIRCLE LIFT PERFORMED:   OPEN SQUAT, RAW SQUAT,  OPEN BENCH PRESS,  RAW BENCH PRESS,  OPEN DEADLIFT , 

RAW BENCH PRESS, PUSH/PULL,  OPEN TOTAL, RAW TOTAL,  BENCH PRESS REPS, CURLS,

 

CIRCLE LEVEL OF RECORD APPLIED FOR:   STATE       NATIONALS        WORLD

AMOUNT LIFTED: ______________ POUNDS. 

 

MEET DIRECTOR: _________________________________________

 

CIRCLE DIVISION:   MENS OPEN   WOMENS OPEN       TEENAGE      OTHER: ______________________________

JUNIOR 20-23    SUBMASTER 33-39    MASTER (SPECIFY AGE HERE) _________

 

*NOTE: IF YOU ARE FORTUNATE ENOUGH TO HOLD SEVERAL RECORDS AND WOULD LIKE
A CERTIFICATE FOR EACH RECORD, IT IS NECESSARY TO FILL OUT AN APPLICATION FOR
EACH RECORD SET TO ASSURE PROPER DOCUMENTATION.

 

____________   (I WOULD LIKE TO RECEIVE A CERTIFICATE) A FEE OF $7.00 PER CERTIFICATE IS REQUIRED.

 

 SEND ALL APPLICATIONS AND MAKE CHECKS AND MONEY ORDER PAYABLE TO:

JESSE RODGERS:    7493 Tanya Dr.  Hixson, Tn.   37341