Bonus Award Declaration Form
This form MUST be filled out completely and signed by each lifter who chooses to compete and be eligible to win any Bonus Award prize. Failure to fill out and return this form before the lifting begins on Sunday, March 16th will result in your forfeiture of any and all Bonus Award Prize you may otherwise be eligible to win. It is the lifters sole responsibility to complete this form for EACH separate bonus award you are qualified to win.
(Lifter completes the top portion only)
Bonus Award Name:_______________________________________________
Name (Print)-_________________________________ Wt. Class-_________ Age-_______ State-_______
Amount of this Bonus Award- $________________
I certify that the information I have submitted is true and accurate. I also agree that if I test positive in any drug test conducted at this event I will voluntarily forfeit all prize money won by myself. I also agree to be responsible for all taxes I may incur by winning this award.
Signature- ____________________________________ Date-_______________
(Office Use Only)
Lifters Total Lbs-______________ lbs OR Lifter’s Total Coefficient-_______________ coeff.
Curl-__________ lbs or Coeff Bench Press-__________ lbs or Coeff Deadlift-__________ lbs or Coeff
Total-_______________ lbs or coefficient
Award Placing-_____________________________
Signed NASA Rep-______________________