Application for APU State Record_WA
Version 0812.20.1


ATTENTION:
- Please complete this form as accurately as possible including the Name of the Referees



(Form Created By: S. Muir)
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Email *
Athlete Information
Name *
First and last name
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Email *
Phone number *
Home Address *
Postal Address *
State *
APU Membership
Membership Number *
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? *
If YES, Please provide details of sporting organisation, period of involvement and last anti-doping test *
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