

Please fill in all fields marked with a *
	Name on Certificate	*
	Street Address	*
	City	*
	State	*
	Zip Code	*
	Country	*
	Country Code
	Birth Month	*
	Birth Day	*
	Birth Year	*
	Valid Email Address	*
	Name Of Meet Where Record Was Set	*
	Month of Record Setting Meet	*
	Day of Record Setting Meet	*
	Year of Record Setting Meet	*
	Division	Unequipped Equipped *
	Cateogry	*
Select if Applicable	POWERLIFTING WORLD RECORD
Select if Applicable	POWERLIFTING EUROPEAN RECORD
Select if Applicable	POWERLIFTING COUNTRY RECORD
Select if Applicable	SINGLE EVENT WORLD RECORD
Select if Applicable	SINGLE EVENT EUROPEAN RECORD
Select if Applicable	SINGLE EVENT COUNTRY RECORD
	Your Weight In Kilos	*
Select if Applicable	Bench
	Kilos Achieved in Bench
Select if Applicable	Squat
	Kilos Achieved in Squat
Select if Applicable	Deadlift
	Kilos Achieved in Deadlift
Select if Applicable	Total
	Kilos Achieved in Total
	Special Instructions