Documentation of Qualifying Total for the
2014 World World Masters Championships

Fill out this form completely and send to:

USAW Masters
130 Brandywine Rd
Savannah, GA 31405

Athlete Name  _________________________________________________________

Club          _________________________________________________________

USAW Reg #    _________________________________________________________

Phone ___________________________  Work _______________________________

Address       _________________________________________________________

City/State    _________________________________________________________

Competition Site  (city/state)  _______________________________________

Sanction #    _________________________________________________________

Date of Competition ___________________________________________________

Note: Must take place between August 11, 2013 and June 1, 2014

Two lift total __________________

Date of Birth  __________________

Bodyweight Class ______________  Bodyweight ___________

Age Group      __________________

We, the undersigned referees and weigher are sure that the weights and scales
have been certified and have judged the correct performance of the above 
total and have checked the weight of the lifter as required by the rules of
the USAW Masters Committee.

PRINT and SIGN (include USAW member number)

Referee _______________________________________________________________

Referee _______________________________________________________________

Referee _______________________________________________________________

Weigher _______________________________________________________________

Signature of Athlete __________________________________________________

NOTE: At least two of the officials must be National Referees