Application for APU State Record_ACT
Version 0812.20
ATTENTION:
- Completion of this form is NOT required for State or National championships. Records set at any other APU championships will require this form to be completed.
- Please complete this form as accurately as possible.
(Form Created By: S. Muir)
* Required
Email address
*
Your email
Athlete Information
Name
*
First and last name
Your answer
Sex
*
Female
Male
Date of Birth
*
MM
/
DD
/
YYYY
Email
*
Your answer
Phone number
*
Your answer
Home Address
*
Your answer
Postal Address
*
Your answer
State
*
ACT
NSW
QLD
VIC
WA
TAS
NT
APU Membership
Membership Number
*
Your answer
If you have been a member for APU for LESS THAN 6 MONTHS, you still may be eligible to hold a record. Have you been a member of a sporting organisation and part of an anti-doping testing pool for a period of no less than and an unbroken period of 6 months prior to performing the claimed record above?
*
Yes
No
If YES, Please provide details of sporting organisation, period of involvement and last anti-doping test
*
Your answer
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