Please Use BLOCK LETTERS

ASA REGISTRATION NUMBER

(See competition condition 3)

Full Name:	Date of Birth:
Club:	Age on 27^th March 2010
Address:	Male/Female
	Tel No:
	Post Code

TIMES TO BE ACHIEVED AFTER 30^th JUNE 2009

Entry will be based on Consideration Times and may be limited at the discretion of the promoter.

Please convert all times to 25metres using the ASA Equivalent Performance Tables.

	EVENT	TIME Converted to 25m	“Split Time” Y/N	OCCASION AND VENUE	DATE
1	50m Freestyle
2	100m Freestyle
3	200m Freestyle
4	400m Freestyle
5	50m Backstroke
6	100m Backstroke
7	200m Backstroke
8	50m Breaststroke
9	100m Breaststroke
10	200m Breaststroke
11	50m Butterfly
12	100m Butterfly
13	200m Butterfly
14	100m Ind Medley
15	200m Ind Medley
16	400m Ind Medley

I hereby declare that the above particulars are correct and that I will abide by the conditions laid down by the Lincolnshire County ASA for this competition.

Signature of Competitor_______________________________________________Date_______________

Certified Correct______________________________________________________Club Secretary

Send the completed form, together with the entry fee of £4.00 per event to the address below. Cheques payable to Lincolnshire County ASA.

Sheila Smith, 48 Rudgard Avenue, Cherry Willingham, Lincoln, LN3 4JG.

CLOSING DATE FOR ENTRIES 10.00pm SATURDAY 16^th JANUARY 2010

LATE OR INCORRECT OR INCOMPLETE ENTRIES WILL NOT BE ACCEPTED.