NASA Unequipped Powerlifting, Bench Press Only & Push Pull

American and World Record Application Only

Copy and Paste This Completed Form To Your E-mail and Submit To:

Fred Ashford - Unequipped Records Chairman

E-mail - Unequipped Records ONLY! All others will be discarded.

All Records Must be submitted within 14 days of the date of the meet to be valid. Any Record Application received after 14 days MAY be refused. These forms MUST be filled out COMPLETELY. ANY blank sections may 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 Copy and Paste to E-mail

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(s).

Please Place an "X" indicating the Division(s) you were entered in during the meet.

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 5 (80+)  - Masters Pure

My Record was set in the following Unequipped portion of the meet (check one): (This is NOT Power Sports- see Power Sports Application)

__Unequipped Push Pull  (Starts in August 2012)    __Unequipped BP (not Power Sports)        __Unequipped Powerlifting

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

Squat______          Bench Press______        Deadlift  ______      Total_______ (Push Pull consists of Total Only)

Total Kgs lifted for this Record-________kgs     (This MUST be in Kilo’s or this record form 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 14 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-_________________