PHSPA High School State Championship
State Record Certificate Request Form
First & Last Name
*
As you would like printed on certificate
Lift Record Achieved
*
Squat
Bench Press
Deadlift
Total
Squat in Pounds
Number Only
Bench Press in Pounds
Number Only
Deadlift in Pounds
Number Only
Total in Pounds
Number Only
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My Products
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Squat Record Certificate
$
12.00
Quantity
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Bench Press Record Certificate
$
12.00
Quantity
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Deadlift Record Certificate
$
12.00
Quantity
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Total Record Certificate
$
12.00
Quantity
1
2
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Credit Card
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