RECORD CERTIFICATE FORM

INSA & INSAA RECORD APPLICATION FORM

PLEASE PRINT & FAX TO: (727) 781-0417

NAME:_______________________________________ DATE OF BIRTH: ________________________________
PHONE: _________________________ E-MAIL: _____________________________________________________
MAILING ADDRESS: ___________________________________________________________________________
CITY: ________________________________________ STATE OR PROVINCE: ___________________________
NATION: _______________________________________ POSTAL OR ZIP CODE: _________________________
WEIGHT AT WEIGH IN: __________DATE & PLACE RECORD WAS SET: _____________________________
CIRCLE LIFT PERFORMED: SQUAT BENCH PRESS DEADLIFT TOTAL
WAS LIFT PERFORMED IN A DRUG TESTED OR NON-TESTED DIVISION?__________________________
CIRCLE LEVEL OF RECORD APPLIED FOR: STATE REGIONAL NATIONAL WORLD
AMOUNT LIFTED______________POUNDS. MEET DIRECTOR______________________________________

CIRCLE DIVISION:

MENS OPEN	WOMENS OPEN	TEENAGE	HIGH SCHOOL
JUNIOR 20-23	SUBMASTER 33-39	MASTER	(SPECIFY AGE HERE): ________

*NOTE: IF YOU 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.
PLEASE CHECK ONE:
____________ $ NO COST (I WOULD LIKE MY RECORD TO BE OFFICIALLY RECORDED)
____________ $7.00 (I WOULD LIKE TO RECEIVE A CERTIFICATE)
____________ $30.00 (I WOULD LIKE TO RECEIVE A CERTIFICATE MOUNTED IN FRAME/ACRYLIC COATED)

SEND ALL APPLICATIONS AND MAKE CHECK OR MONEY ORDER PAYABLE TO:
NOVA FITNESS
4360 WESTERN CENTER BLVD., PMB # 207
FORT WORTH, TEXAS, 76137
ALLOW 2-4 WEEKS DELIVERY TIME PLEASE!

For further information please contact David Newingham

tel.727.492.0723 or novafitness@earthlink.net