YOUTH OLYMPIC GAMES – ATHLETE SUPPORT OPTION 2 – YOG QUALIFICATION TECHNICAL REPORT FORM National Olympic Committee Athlete’s given name(s) Athlete’s family name Sport Discipline N° Dates Competition name and location Qualification obtained Yes/No Ticket cost Ticket cost (Local currency) (USD) Total I, the undersigned, President/Secretary General, of the above-mentioned NOC, certify that the information provided above is true and accurate. Name, function (President or Secretary General) and signature: Date: Stamp This form is also available on NOCnet http://extranet.olympic.org/nocnet Olympic Solidarity – 2013–2016 World Programmes 1