American Powerlifting Committee National National Powerlifting and 
Bench Press Championships.
June 5, 6, 7,  2009
Peoria, Il., USA

Name___________________________________________________________

Address__________________________________________________________

City _______________________State__________Zip______________________

Phone________________________________ Birth date____________________

Email____________________________________________________________

Release From Liability. Read this carefully:
By signing this you will be giving up important rights. In consideration of my acceptance of my entry form in this powerlifting/benchpress competition, I understand that I am legally bound for not only myself but also for my heirs, my executors, and my administrators. In signing this release from liability I waive and release Stephen Parkhurst, Greg Gordon, The American Powerlifitng Committee, all Officials, Referees, Spotter/Loaders and any other person or firm taking part in this competition from any and all liability which may arise from this competition. I understand all of the above for my acceptance of my entry in this competition. By signing this entry form I affirm that all the information on this form is correct.

Signature________________________________________   APC Card Number_______________

Parent or guardian if under 18_______________________________________________________

Entry fee: $85.00 – Bench Press Division $85.00, both $125.00-Team entry - $50.00.

24 hour weigh in beginning at 10:00 AM Thursday June 4, 2009.

Entry Deadline May 22, 2008  
$25.00 late fee

Send check payable to Stephen Parkhurst and entry form to: Stephen Parkhurst, 3021 Springfield Rd., East Peoria, Il. 61611.  
 www.americanpowerliftngcommittee.com

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