National Powerlifting

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PL'ing, BP & DL Credit Card Entry Form Late Fee Begins on July 5th, 2011

STEP 1

Complete Entry Form and click "Submit" then proceed to STEP 2 if paying by PayPal

Late Fee after Deadline Date is $10.00 additional fee for the First Division Entered

Please Accept My Entry For the 2011 Grand Nationals

First Name- Last Name-

Wt. Class- Age- DOB- Phone-

Address- City-

State- Zip- E-Mail-

Equipped Powerlifting (suits, shirts, wraps & belt allowed) Division(s) Entered-, , ,

    Unequipped Powerlifting (wraps & belt allowed) Division(s) Entered-, , ,

    Equipped Bench (shirts, wraps & belt allowed) Only Division(s) Entered-, ,

    Unequipped Bench (wraps & belt allowed) Only Division(s) Entered-, ,

    Power Sports Full Meet (curl+bp+dl=total) Division(s) Entered -, , ,

    Power Sports Individual Lift (curl or bp or dl) Division(s) Entered -, , ,

    Push Pull (equipped) Division(s) Entered (fill in)-, , ,

    Grand Total Number of Divisions Entering-

    Total Amount I will be paying by PayPal or by Phone -$  Do Not Forget To Add Late Fee's after 7.5.11



Call 405-527-8513 if calling in your Credit Card

I will be paying by the following method -

Submit this form and THEN either call in your Credit Card Number or Pay by PayPal below.

Comments or Questions-

Read this Waiver Completely Before Submitting - All Unsigned Entries Will Be Returned
In consideration of your acceptance of this entry, I hereby waive, for myself, my heirs and assigns, any and all claims for injury or damages which I may incur by virtue of my competing in this contest as against Rich Peters, NASA LLC Powerlifting, Des Moines Strength Institute, Dale Rhoades, the facility used and any of their agents and employees. I also realize that the sport of Powerlifting is a high risk sport and that I could be injured. I certify that I am in good physical health and have no serious health problems and that I assume full responsibility for such conditions. I realize that if I use the False Grip or Open Grip that it is a dangerous method of BP'ing and I assume full responsibility if I choose to use this method to BP. I also realize that I am fully responsible for my well being and safety in the warm up room, on the lifting platform and while I am lifting at this event. I also certify, by my signature, that I have read this waiver and fully understand and accept it’s terms. I do hereby verify my acceptance by my signature below. I also give NASA, Rich Peters and all other parties involved in this meet permission to post my name and make my name public if I fail any Drug Test. Do Not Sign This Waiver Before Reading It Fully and Carefully. If you do not accept it’s terms, DO NOT sign it.

I agree to the terms of this waiver and do so indicate by my submission this Credit Card Entry.

Security Word - nasa101

Please type Security Word here-

Your Entry Is NOT Complete Until You Pay Through PayPal In Step 2 - Keep Your Receipt From PayPal And Bring It To The Meet

I Realize that this Competition is an Anabolic Steroid Free Meet
I to the terms of this waiver (Initials)-

STEP-2

PayPal Credit Card Entry - Secured

Solution Graphics

Pay Your Entry Fee's By Credit Card & E-Check Here

Official Weigh-In Times

Men’s Weight Classes

Women’s Weight Class

Power Sports Entry Fee’s Only

Return Entry and Entry Fee’s

Team Entry Fee:

DO NOT MAIL ENTRIES AFTER 7-5-11 - Add Late Fee's or Entry Will Be Returned