Full Mailing Address________________________________________________________________________________________

City________________________________________State_________________________Zip Code_________________________

Phone(____)_______________________Fax(____)_____________________E-Mail____________________________________

National Federation APF � AAPF � Both � Registration Number________________________________

Date of Birth_______________________________Age Last Birthday_____________________________________

Name of Competition____________________________________________Location_____________________________________

Date__________________________________ Competition Body Weight ___________kg Weight Class ___________kg

National Records can be set at National, State, and International competitions. According to the APF/AAPF Rules no record will be considered unless entered on this Records Claim Form, which must be duly signed by the Athlete, the Referees adjudicating the lift(s), the Official Weigher and the appointed Technical Officer of the Competition. Certified platform scales must have been used at the weigh in and a copy of the certification certificate attached to this claim. The bar and weights must have been weighed before the competition or immediately after the Record Attempt. The Athletes costume and personal equipment must have been inspected and conform to the requirements of the APF/AAPF Rules. A minimum of three National Referees affiliated to the APF/AAPF is required to certify a Record.

We have witnessed the correct performance of the above lift(s) and have checked the weight of the bars and discs. The lifter weighed in within 24 hours of the competition. The lifter and his/her attire have been checked and conform to the requirements of the APF/AAPF Rules. We are current members in good standing with the American Powerlifting Federation.

Signature_______________________________Signature_____________________________Signature_______________________

Technical Officer Signature_______________________________Official Weigher Signature________________________________

I have checked all data and agree all is correct: Athletes Signature_____________________________Date____________________