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 $12.00 per Certificate to : Jesse Rodgers   7493 Tanya Dr.   Harrison,  Tn.   37341 

 

1. NAME ______________________________ DATE OF BIRTH _______PHONE _____________

 

2. MAILING ADDRESS: ____________________________________________________________

 

3. CITY: ________________________________________ STATE: ________________

 

4. POSTAL OR ZIP CODE: ______________________  CONTEST WEIGHT: ____________

 

5. DATE & PLACE YOU SET RECORD: _______________________________________________

 

6.NAME OF THE CONTEST THAT YOU WERE IN: _____________________________________

 

7. CIRCLE LIFT PERFORMED:  RAW     SINGLE PLY        MULTI_PLY

 

8. CIRCLE THE ONE THAT PERTAINS TO YOU:   POWERLIFTING   PUSH/PULL    

    SQUAT ONLY     BENCH ONLY    DEADLIFT ONLY     BENCH PRESS REPS,      CURLS,

 

9. CIRCLE LEVEL OF RECORD APPLIED FOR:   STATE       NATIONALS        WORLD

 

10. AMOUNT LIFTED: ______________ POUNDS. 

 

11. MEET DIRECTOR: _________________________________________

 

12. CIRCLE DIVISION:   MENS OPEN   WOMENS OPEN       TEENAGE 13-15,  16-17,  18-19     

 

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

 

14. DID YOU ANSWER EVERY QUESTION ABOVE?   YES     NO

 

*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 $12.00 PER CERTIFICATE IS REQUIRED.

 

 SEND ALL APPLICATIONS AND MAKE CHECKS AND MONEY ORDER PAYABLE TO:  JESSE RODGERS:    7493 Tanya Dr.  Hixson, Tn.   37341