REQUEST FORM
RELAY ALL-AMERICAN PATCH AND CERTIFICATE

Relay event: circle one      MEN     WOMEN    MIXED                          

Relay Type: circle one       FREE    MEDLEY

Relay distance: circle one   200     400      800

Course: circle one           SCY     SCM      LCM             

Year of swim ______________     Age Group ______________

Relay member(s) requesting All-American patch and certificate:  ($5.00 each member)

          1. ____________________________________

          2. ____________________________________

          3. ____________________________________

          4. ____________________________________


Send patch and certificate(s) to:

Name      _________________________________

Address   _________________________________

          _________________________________

          _________________________________


Mail Payment To:

United States Masters Swimming National Office
P.O. Box 185
Londonderry NH 03053-0185


Make checks payable to:

United States Masters Swimming