Application-No by asafwewe

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									 CHAIR ANTI-DOPING COMMITTEE:                                           Tels. +61 8 95311866 – +61 8 95311845
 Dr Patricia Wallace MBCHB                                              Fax. +61 8 9513030
                                   Federation Internationale de
 PO Box 285, Pinjarra                                                   Mob +61 418 920 466
 Western Australia 6208                   Roller Sports                 Internet. http://www.rollersports.org
                                                                        E-mail. pwallace@southwest.com.au


                                                                        Application No.:…………..
                      Therapeutic Use Exemptions
                         Abbreviated Process
       (beta-2agonists by inhalation, glucocorticosteriods by non-systemic routes)

I apply for approval from (Anti-Doping Organization) for the therapeutic use of a prohibited
substance on the WADA List of Prohibited Substances and Prohibited Methods that is subject to
the Abbreviated Therapeutic Use Exemption Application Process.

      Glucocorticoid (non systemic route)                 Beta agonist (by inhalation)


                                  Please Complete All Sections                L
1. Athlete Information
Surname: ………………………………….
                                                                         T
                                             Given Names: ………………………………………… IA
Female:           Male:
                                                                  E N
Address: …………………………………………………………………………………………………….

                                                          F ID
City: ……………………………….. Country: ……………………………… Postcode: ……………...
                                            N
                                          CO
Date of Birth (d/m/y): …………………………………..

Tel. Work: ………………………… Tel. Home: ……………………….. Mobile: ……………………..


                        LY
Email: ………………………………………….. Fax: …………………………………………………….


                      CT
Sport: ……………………………… Discipline/Position: …………………………………………………


                    RI
National Sporting Organization: …………………………………………………………………………..


             ST
If Athlete with disability, indicate disability: ………………………………………………………………


2. Notifying Medical Practitioner
Name, qualifications and medical specialty (see note 1): ……………………………………………...

…………………………………………………………………………………………………………………

Address: ……………………………………………………………………………………………………..

………………………………………………….. Email Address: …………………………………………

Tel. Work: ……………………………………. Tel. Home: ……………………………………………...

Mobile: ……………………………………….. Fax: ……………………………………………………...




                                                                                                        1
 CHAIR ANTI-DOPING COMMITTEE:                                              Tels. +61 8 95311866 – +61 8 95311845
 Dr Patricia Wallace MBCHB                                                 Fax. +61 8 9513030
                                      Federation Internationale de
 PO Box 285, Pinjarra                                                      Mob +61 418 920 466
 Western Australia 6208                      Roller Sports                 Internet. http://www.rollersports.org
                                                                           E-mail. pwallace@southwest.com.au
                                                                           Application No.:…………..
3. Medical Information
Diagnosis: …………………………………………………………………………………………………..

Medical examination (s) / test (s) performed: ……………………………………………………………

…………………………………………………………………………………………………………………


Prohibited Substance (s) :       Dose of                  Route of                  Frequency of
                                 administration           administration            administration



                                                                                    L
                                                                               T IA
                                                                   EN
                                                              F ID
Anticipated duration of
                                                  ON
this medication plan
                                                C
Additional Information
                            LY
                          CT
…………………………………………………………………………………………………………………



                        RI
…………………………………………………………………………………………………………………



                 ST
…………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………



4. Medical practitioner’s and athlete’s declaration
I, ………………………………………………… certify the above-mentioned substance/s for the
above names athlete has been/are to be administered as the correct treatment for the above
medial condition. I further certify that the use of alternative medications not on the Prohibited List
would be unsatisfactory for the treatment of the above named medical condition.
Specify reasons: …………………………………………………………………………………………….

Signature of Medical Practitioner: …………………………………………. Date: ………………….




                                                                                                           2
 CHAIR ANTI-DOPING COMMITTEE:                                          Tels. +61 8 95311866 – +61 8 95311845
 Dr Patricia Wallace MBCHB                                             Fax. +61 8 9513030
                                    Federation Internationale de
 PO Box 285, Pinjarra                                                  Mob +61 418 920 466
 Western Australia 6208                    Roller Sports               Internet. http://www.rollersports.org
                                                                       E-mail. pwallace@southwest.com.au




I, …………………………………………………. certify that the information under 1. is accurate and
that I am requesting approval to use a Substance or Method from the WADA Prohibited List. I
authorize the release of personal medical information to the Anti-Doping Organization as well as
to WADA staff and to the WADA TUEC (Therapeutic Use Exemption Committee) as well as to
other Anti-Doping Organizations under the provisions of the Code. I understand that if I ever wish
to revoke the right of Anti-Doping Organization TUEC or WADA TUEC to obtain my health
information on my behalf, I must notify my medical practitioner in writing of that fact.

Athlete’s Signature: ……………………………………………………………. Date: …………………

Parent’s/Guardian’s signature: ………………………………………………. Date: …………………
(if the athlete is a minor or has a disability preventing him/her to sign this form, a parent or
guardian shall sign together with or on behalf of the athlete).

    Note 1        Name, qualifications and medical specialty
                  For example : Dr AB Cook, MD FRACP, Castro-enterologist.


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Dr Patricia Wallace MBCHB
FIRS Anti-doping Committee
PO Box 285, Pinjarra
Western Australia 6208

Phone 61 8 95311866 – 61 8 95311845
Mob +61 418 920 466
Email pwallace@southwest.com.au




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