ACTA Australian Clay Target Association

Long Break Recognition Application Form

This form is to be used to claim a Long Run, Grand Slam or Masters Award and is to be accompanied by the necessary verification (attached scanned copy) of the break/s for all breaks.

I would like to request recognition for the following long break(s):

Name:		Membership #:
Address:		Email Address:

Break Requests:
Break 1 achieved at:
Event:
Date:		Break:

Break 2 achieved at:
Event:
Date:		Break:

Break 3 achieved at:
Event:
Date:		Break:

Please upload your scanned documentation here (e.g. score sheets)
Attachment 1		Attachment 2
Attachment 3		Attachment 4
Comments:
Please complete the security feature: PLEASE CHECK YOU HAVE ENTERED ALL THE NECESSARY FIELDS.

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