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Fill and Sign the Sports Medical Certificate Form

Fill and Sign the Sports Medical Certificate Form

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3rd FINA WORLD JUNIOR SWIMMING CHAMPIONSHIPS 16-21 August 2011 in Lima, Perù 2nd PRELIMINARY ENTRY FORM CLOSING DATE FOR APPLICATION: 15 MAY 2011 Send this form to: see bottom Name of the Federation / Nom de la Fédération Address / Adresse Postal Code / Code postal Country / Pays Phone / Téléphone Fax / Fax Name of contact person / Nom de la personne de contact Position / Fonction Do you intend to participate? / Désirez-vous participer? Yes / Oui No / Non Estimated number of people / Nombre estimé de personnes Competitors / Compétiteurs Officials / Officiels Date / Date Federation seal / Tampon de la Fédération President or Secretary of Federation / Président ou Secretaire Général de la Fédération Name / Nom Signature PLEASE RETURN THIS FORM TO THE FINA OFFICE IN LAUSANNE (SUI) NO LATER THAN 15th MAY 2011 BY POST: FINA, AV. DE L'AVANT-POSTE 4, 1005 LAUSANNE, SWITZERLAND BY FAX: (41-21) 312 66 10

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