Liberty Nationals Wrestling Championships

CONTACT:_________________________ CLUB NAME:_________________________
ADDRESS LINE 1:__________________________________________________
ADDRESS LINE 2:__________________________________________________
PHONE:_________________________ FAX:_________________________
TOTAL # OF ENTREES_______________ X $47 FEE__________ = $__________

WRESTLERS
FIRST NAME 		LAST NAME BIRTHDATE AGE LBS RATING WIN LOSS USAW
CARD #
6 And Under
 
 
 
8 And Under
 
 
 
10 And Under
 
 
 
12 And Under
 
 
 
14 And Under
 
 
 
High School
 
 
 

AA National Placer    A State Placer             B State Qualifier           C Regional Qualifier

LIST ALL NATIONAL AND STATE PLACINGS ON REVERSE SIDE OF THIS DOCUMENT
PLEASE IDENTIFY WOMEN'S DIVISION WRESTLERS
ENTRY DEADLINE: February 9, 2010
Make Checks Payable to Liberty Nationals Wrestling Championships
Mail Entry to: Liberty Nationals, 950 S. Kent Bdlg. C., Liberty, MO 64068