NQ Championships 24-26 September 2004

Athletes wishing to make themselves available for selection in the Northern Territory Team for the 2004 North Queensland Championships must complete this form and submit it to Northern Territory Athletics, PO Box 40375, CASUARINA NT 0811, with a $50 refundable security bond no later than the 6 August 2004. (Late entry fee $10)

Name
Postal Address
Email
B/H	A/H
Mobile	Fax:
D.O.B	NTA Rego Number
Club	Male/ Female

PERFORMANCE DETAILS

Please list your 2 best performances since 1^st April 2004 for each event you wish to be considered

Event	Performance Time/Distance	Place	Competition National/Club/ Territory	Date	Venue
	1.
	2.
	1.
	2.
	1.
	2.
	1.
	2.
	1.
	2.

Athlete Signature Date

Parents/Guardian Signature if athlete under 18 years of age