| Seminar Location: | Date of Seminar: |
| Name of Applicant: | |
| Address: | |
| City: | Province: |
| Postal Code: | Phone: |
| E-Mail Address: | |
| Present Level: | Date Received: |
| Arm Wrestling Experience(years) | Experience as an Organizer(years) |
| Experience as a Referee(years) | As a Head Referee(years) |
Local/Sanction/Circuit/Provincial/National |
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| Level Applying For: | Level 1 | Level 2 | Level 3 | Masters |
| Signature | Amount Received $ |