(Please type or print clearly)

LAST NAME: ___________________________________________________________

FIRST NAME: ___________________________________________________________

NICKNAME: ____________________________________________________________

ADDRESS: _____________________________________________________________

TELEPHONE: ___________________________________________________________

DATE OF BIRTH: ________________________________________________________

PLACE OF BIRTH: _______________________________________________________

CITIZENSHIP OR COUNTRY REPRESENTED: ______________________________

IF DECEASED, DATE OF DEATH: _________________________________________


PLEASE INDICATE THE CATEGORY OF THE NOMINEE:


	__________ SWIMMER		__________ FEMALE

	__________ DIVER		__________ MALE

	__________ WATER POLO PLAYER

	__________ SYNCHRONIZED SWIMMER


(Additional copies may be made of this form.)


I.  WORLD RECORD HISTORY


	Number of individual World Records attained: _________________

	Number of relay World Records attained: _____________________


CHRONOLOGICALLY LIST EACH WORLD RECORD SET:  Include age groups,
event, time, date, location.










II.  WORLD CHAMPIONSHIP HISTORY

Number of Medals attained:				Gold __________

						      Silver __________

						      Bronze __________

					Other final placings __________


CHRONOLOGICALLY LIST THE WORLD CHAMPIONSHIPS IN WHICH THE NOMINEE 
PARTICIPATED:  Include age groups, events, relays, results, times, records 
established, games, position, goals scored, honors received, etc.








III.  REGIONAL RECORDS AND CHAMPIONSHIPS (ie: European Championships (LEN),
Pan American Games, etc.):

	Name of Meet:  ______________________________________________

	Number of Medals attained:			Gold __________

						      Silver __________

						      Bronze __________

					Other final placings __________


CHRONOLOGICALLY LIST EACH EVENT:  Include age groups, relays, times,
records established, games, position, goals scored, honors received, results, etc.










IV.  NATIONAL CHAMPIONSHIP AND NATIONAL RECORD HISTORY

	Number of National Championships attained:	__________

	Number of National Records set:			__________


CHRONOLOGICALLY LIST EACH NATIONAL CHAMPIONSHIP ATTAINED:
Include events, times, scores, dates, locations, games, position, goals scored, honors 
received, etc.  Place an asterisk (*) in front of each championship that was also a
national record.








V.  LIST SPECIAL HONORS AND AWARDS RECEIVED:







VI.  LIST INTERNATIONAL AND NATIONAL ORGANIZATIONS 
AND ASSOCIATIONS ON WHICH THE NOMINEE SERVED OR WAS APPOINTED







VII.  LIST "MILESTONE" ACHIEVEMENTS OR "FIRSTS" IN THE SPORT WHICH 
WERE OBTAINED BY THE NOMINEE:







VIII.  ADDITIONAL INFORMATION OR DIALOGUE WHICH IS HELPFUL IN 
PREPARING INFORMATION FOR THIS HONOREE:











						Submitted by:

						_________________________
						Print Name

						_________________________
						Signed

						_________________________
						Date

						_________________________
						Telephone