ADFPF AMERICAN, NATIONAL & STATE RECORD CERTIFICATES

NAME AS YOU WANT IT TO APPEAR ON CERTIFICATE: (PLEASE PRINT CLEARLY)

ADDRESS YOU WANT THE CERTIFICATE MAILED TO: (PLEASE PRINT CLEARLY)

NAME OF MEET WHERE RECORD WAS SET:

DATE OF RECORD SETTING MEET:_______________. BIRTH DATE: _______________.

¨ UNEQUIPPED DIVISION ¨ EQUIPPED DIVISION

CATEGORY:

¨ OPEN ¨ MASTER’S

¨ TEEN 1 (14-15 YRS OF AGE) ¨ 1 ¨ 6

¨ TEEN 2 (16-17 YRS OF AGE) ¨ 2 ¨ 7

¨ TEEN 3 (18-19 YRS OF AGE) ¨ 3 ¨ 8

¨ JUNIOR (20-23 YRS OF AGE) ¨ 4 ¨ 9

¨ 5 ¨ 10

¨ POLICE/FIRE/MILITARY ¨ NATIONAL SINGLE EVENT RECORD

¨ AMERICAN SINGLE EVENT RECORD ¨ NATIONAL POWERLIFTING RECORD

¨ AMERICAN POWERLIFTING RECORD ¨ STATE RECORD

WEIGHT CLASS IN KILOS: ______________.

¨ SQUAT: ____________kg. /_______________ lbs.

¨ BENCH PRESS: ____________kg./ _______________ lbs.

¨ DEADLIFT: ____________kg./ _______________ lbs.

¨ TOTAL: ____________kg./________________lbs.

TO PLACE ORDER VIA INTERNET SEND REQUEST AND INFORMATION TO: rahrah923@yahoo.com

All records will be verified by the A.D.F.P.F. Each certificate is $10.00. Check or money order should be made payable to Susan McCombs. Payment should be attached to the form. If ordering on the internet please mail to:

Susan McCombs

PO Box 272 – 207 W Hickory Street

Industry, IL 61440