APPLICATION for RECORD This Form Shall Be Used for Canadian Records Please Follow Instruction to Ensure Proper Completion
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APPLICATION FOR RECORD This form shall be used for Canadian records Please follow instruction to ensure proper completion. Instructions: For TRACK events: use sections 1, 2, 3, either 4a or 4c (only if event longer than 800m), 6 (only for outdoor events shorter than 300m), 9*, and 10. For FIELD events: use sections 1, 2, 5, 6 (for outdoor events where applicable), 7, 9*, and 10. For Combined Events: use sections 1, 2, 2a, 3, 4a, 5, 6, (for outdoor events where applicable), 7, 9*, and 10. For ROAD Events: use sections 1, 2, 3, 4a or 4b or 4c, 8, 9*, and 10. For RACE WALKING Events: use sections 1, 2, 3, 4a or 4b or 4c, 8, 8a, 9*, and 10. *Note Athletics Canada Rule 179: All athletes who establish pending Canadian Records in a bona fide competition must be available for doping control for testing, if selected. In the event there is no provision for doping control, or if the athlete was not selected for testing, the athlete must inform Athletics Canada within 24 hours of their notification that a pending record has been established via electronic message that a pending record has been set. It is then the responsibility of Athletics Canada to determine if target testing will occur. This form must be completed and dispatched within 30 days of the Canadian Record performance and, if after such time, accompanied by a fee of $50.00 CDN (see AC Rule 183) Send full documentation to: Athletics Canada / Attention Records Manager 105-2141 Thurston Drive, Ottawa ON, K1G 6C9 E-mail: [email protected]; Fax: 613-260-0341 To Athletics Canada: Application is hereby made for the ratification of the following a record, in support of which, the following information is submitted (please type or use block capitals, tick where appropriate): 1. Description of Record: U-18 (Youth)* U-20 (Junior)* U-23 (Espoir)* Open Age (Senior) Para (Class: ) All-Comers’ (Open Age only) *application must be accompanied by copy of birth certificate or proof of age (where such proof has not previously been provided to Athletics Canada) Event: Men Women / Indoor Outdoor Road Competition Name: Date (DD/MM/YY): / / Time of Event: Location / Facility: City: Province Country Record Claimed (time, distance, height, or points achieved): Print Full Name of Competitor, Club, Province (print first name first; list relay members in their running order): 2. Result of the event: The name of the first three competitors and their performances: 1st: Result: 2nd: Result: 3rd: Result: a. COMBINED EVENTS: Please include each event performance. Include wind reading and implement weight (where applicable). Please fill out the events in which you competed. Track Event Result Wind Field Event Result Wind Implement Reading (if Reading (if weight applicable) applicable) 100m (60m indoor) High Jump 200m Pole Vault 400m Long Jump 800m Shot Put 100/110mH (60mH Discus indoor) 1500m (1000m indoor) Javelin 3. Starter’s Certificate: I certify I was the starter and that the start of this race was in accordance with World Athletics or applicable Rules Name of starter: Signature: Zero Control Test performed at start of session? (y/n) if no, date and time of last test: 4. TIMING CERTIFICATE a. Fully Automatic Timing Certificate (if applicable): A fully automatic timing device was used; manufactured by: As chief Photo Finish Judge, I certify the time recorded was , and this was the official time. Attach photo if available. Printed Name: Signature: b. Transponder Timing Certificate (if applicable): A transponder timing device was used; manufactured by: As chief Transponder Timing Judge, I certify the time recorded was , and this was the official time. Printed Name: Signature: c. Hand Timing Certificate (if applicable): I, the undersigned official timekeeper of the event mentioned on this form, do hereby certify that the time opposite my signature was the exact time recorded by my watch Time: Name: Signature: Time: Name: Signature: Time: Name: Signature: As Chief Timekeeper or Referee, I confirm that the Timekeepers exhibited their watches to me and that the times were as stated Printed Name: Signature: 5. Field Judge Certificate: I hereby certify that the measurement stated is exact as measured in accordance with Athletics Canada and World Athletics Rules. I also certify the circle or runway compiled with Athletics Canada and World Athletics specifications. (Note: If officiating Long Jump or Triple jump ensure to complete wind reading section – point 6). Printed Name: Signature: 6. Wind Gauge Certificate: Wind speed in the direction of running: m/s * Outdoor events shorter than 300m, Long Jump and Triple Jump Only * Name of operator: Signature: 7. Implement Certificate: I hereby certify that the implement used in the record claimed was measured, weighed and examined before and after the performance and conforms to Athletics Canada and World Athletics Rules. Manufacturer: Model: Printed Name: Signature: 8. Course: I, an World Athletics / AIMS approved course measurer, hereby certify that I have measured the course over which this event was held Measured race distance: The start and finish of the course, measured along a theoretical straight line between them, are not further apart than 50% of the race distance The difference in elevation between start and finish does not exceed one in a thousand (i.e., 1m per km). Measurer: Qualification: Signature: I, an World Athletics / AIMS approved course measurer in possession of the complete measurement data and maps, certify that the course measured was the course completed by the athlete Measurer: Qualification: Signature: Alternatively, attach copy of official course certification documentation. a. Race Walking Judges: I, a certified Race Walking Judge, did officiate during the competition Judge: Qualification: Signature: Judge: Qualification: Signature: Judge: Qualification: Signature: Chief Race Walking Judge: Qualification: Signature: 9. Doping Control (if in effect at the competition and if the athlete was selected for doping control): I, as certified Doping Control Officer for the competition, certify that a sample for doping was obtained from the above mentioned athlete in my presence and dispatched to the following laboratory: Doping Control Date: Laboratory: Printed Name: Signature: Note Athletics Canada Rule 179: All athletes who establish pending Canadian Records in a bona fide competition must be available for doping control for testing, if selected. In the event there is no provision for doping control, or if the athlete was not selected for testing, the athlete must inform Athletics Canada within 24 hours of their notification that a pending record has been established via electronic message that a pending record has been set. It is then the responsibility of Athletics Canada to determine if target testing will occur. 10. Guarantee by Referee: I hereby certify that all the information recorded on this form is accurate, that the officials conducting the Meeting were duly qualified and that the appropriate Athletics Canada and World Athletics Rules of competition were complied with. Name of Referee: Signature: Date: Enclosed with this record claim: o Copy of Photo-Finish if Fully Automatic Timing is in use o Copy of Zero Control Test image (where applicable) o U-18, U-20, U-23 copies of birth certificate or other proof of age (where not previously provided to Athletics Canada) o Copy of official result sheet o Copy of event program o Measurement report (where applicable) o Field event implement recertification report (where applicable) ATHLETICS CANADA APPROVAL Event Manager: Signature: NOTE: There’s no need to submit documentation for records achieved at: Olympic Games NACAC Championships World Athletics Diamond League Events Paralympic Games NACAC U23 Championships World Athletics World Challenge Meetings and Competitions (including Hammer Throw, World Athletics World Championships NACAC U18 Championships Combined Events, and Race Walking) World Para Athletics (WPA) Championships WPA Area Championships WPA Grand Prix Events World Athletics World U20 Championships FISU Games World Athletics Gold, Silver, and Bronze WPA U20 Championships Commonwealth Games Label Road Races U18 Olympic Games Commonwealth U18 Games World Athletics World Indoor Tour Events Pan American Games Francophone Games U Sports Championships Parapan American Games Other World, Continental, Regional, Area or NCAA and NAIA Championships Group Championships or Games Panamerican U20 Championships All other Athletics Canada National Team Competitions Form Revised: Sep 15, 2021 .