Application for an Alberta Powerlifting Record

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Name ________________________________________  Phone No. ____________________________

Address _____________________________________  City _________________________________

Province ____________________________________  Postal Code __________________________

Age ______ Date of Birth - Month ______ Day ______ Year ______  Male [  ]  Female [  ]


Name of Contest _____________________________________________________________________

Location of Contest ___________________________________  Date _______________________

Meet Director__________________________________________

Lifters Weight Class _________________  Actual Body Weight  _________________________


Please Circle Correct Category(s)

OPEN   SUB-JUNIOR   JUNIOR   MASTER 40-49   MASTER 50-59   MASTER 60-69   MASTER 70 +


Please list ALL successful lifts including total, and Circle All Record Lifts

Three Lift Contest

First Attempt        Second Attempt       Third Attempt        Fourth Attempt

Squat ______ kg      Squat ______ kg      Squat ______ kg      Squat ______ kg

Bench ______ kg      Bench ______ kg      Bench ______ kg      Bench ______ kg

Dead ______ kg       Dead ______ kg       Dead ______ kg       Dead ______ kg

Total ______ kg


Bench Only Contest

Bench 1 ______ kg    Bench 2 ______ kg    Bench 3 ______ kg    Bench 4 ______ kg


Weigh-in Official _______________________ Drug Control Number _______________________

Drug Test Official (if CPU) ____________________ Laboratory _________________________

** ATTACH A COPY OF THE OFFICIAL RESULTS OF THE MEET SIGNED BY ALL REFEREES **