UCI CYCLING REGULATIONS  Appendix 1  UCI  REQUEST FOR WORLD RECORD HOMOLOGATION  Date of the performance: Date of the request sent to UCI: (The request shall reach the UCI no later than 1 month after the performance - Immediate notification by  fax to UCI)  Secretary General of National Federation: Velodrome  Location of Track (City and Country): Track Measurement........................................... metres  Material........................................... (wood, etc.)  Covered or Open: UCI Homologation Date: Information for Processing  Request for World Record / Best Performance Homologation for: (Men - Women - Junior Men - Junior Women – Masters Men – Masters Women)  Distance: Start (standing or flying): Date of attempt or event: ....................................................................................... Result: Complete name of the rider: .................................................................................. Nationality: UCI ID: ................................................................................Licence number: Laboratory in charge of Doping Control analysis: Time of the attempt or event: During an event / Special Attempt: Resume of record: Attestation of the result by Officials  We, the undersigned officials confirm that the record information as set out within this document was  achieved according to the UCI Regulation.  Position  Name (family)  Given Name  Signature  91  PARA-CYCLING  E0121 