USA Powerlifting™

Conditions Of Membership: As a condition of membership to USAPL, I agree to follow and obey all rules, regulations, and drug testing procedures of USAPL. I further agree that the rules, regulations, and drug testing procedures are subject to change at any time and that I agree to obey any new or changed rules, regulations, and drug testing procedures as a condition of continued membership. I agree that my membership may be revoked temporarily or permanently, suspended, and/or denied for my failure to obey USAPL rules, regulations, and drug testing procedures. I will voluntarily submit to any drug testing procedure that USAPL has approved in its rules, regulations, and drug testing procedures. If I do test positive for a banned substance, I agree that the results of the test are conclusive, and I further agree to accept the consequences of that positive test regarding my membership. As a condition of membership to USAPL, I understand and accept that I am prohibited from using any substance or doping method that is banned by the United States Olympic Committee. It is my sole responsibility to stay current with any USOC banned substance or doping method, including those most recently banned. I further accept sole responsibility for what I take into my body and that should I consume a banned substance unknowingly, and test positive for that banned substance, I shall be solely responsible for the consumption of that banned substance and shall accept the results and consequences of that test. If I am suspended from membership for any reason, including testing positive for a banned substance or doping method, I permit USAPL to publish my name as a suspended member and/or a member who is suspended for testing positive for a banned substance or doping method on the Internet, in Powerlifting USA, or any other publication that USAPL so chooses.

(formerly ADFPA) Membership Application • PO Box 668., Columbia City, IN 46725 (260) 248-4889 • (260) 248-4879 fax • •

SIGNATURE: ________________________________________ If under 21 yrs., Parent Initial: _______ Date: ____________ Prior Reg. # ________________ Name: Eugene DePree Jr Address: 2714 NE 27th ST Date Of Birth: 02-08-1979 Age: 31 __________________________________ Sex: Male Phone: ( 352 ) 390-6457 City: Ocala U.S. Citizen? Yes USAPL Registered Club Represented: E-Mail: State: FL Zip Code: 34470

Membership Prices: (please circle one) • Adult - $45.00 • High School Division (Full year; any meet) - $30.00 • Special Olympian - $10.00 • High School Seasonal (6 mo. HS ONLY meets; good Dec. 1 thru May 31) - $15.00 • Upgrade from current HS Seasonal to HS Div. Full year - $15.00 Competing Divisions: (please circle all that apply) Collegiate Military Police & Fire Open Youth (12-13 yrs.) Teen (14-19 yrs.) Junior (20-23 yrs.) Master (40 yrs. & up) High School - Full Year High School Seasonal - 6 mo. Dec. 1 - May31 Special Olympian

USAPL Merchandise: (please circle choices) •T-Shirt - $15.00 (size ___ qty. ___)(colors: royal blue, red, black) •Polo Shirt - $30.00(s-xl) $32.500(xxl & up) (size ___ qty. ___)(colors: white) •1/4 Zip Navy Sweatshirt - $40.00(s-xl) $45.00(xxl & up) (size ___ qty. ___) •White Referee Designation Polo - $30.00(s-xl) $32.50(xxl & up) (size ___ qty. ___) •Logo Patch - $5.00 (qty. ___) (Shpg for patch: .50) •Lifter Classification Patch - $5.00 (qty. ___) (must provide meet results) •Hats - $15.00 (qty.___)(color: navy) Check/Money Order # ____________________ Credit Card: Visa-Mastercard-Discover Exp. Date: __________ ____________________ Card # __________ - __________ - __________ - __________ Cardholder Signature: ________________________________

Membership Price: $ ____________________ Merchandise Total: $ Merchandise Shipping: $6.50

Total Purchased: $ ____________________
(White Original – National Office • Yellow – Seller’s Copy • Pink – Lifter’s Copy)

All memberships expire Dec 31 of year purchased
(Memberships purchased Nov/Dec expire the following year-end)

Sign up to vote on this title
UsefulNot useful