Free 45727.FH11 - Indiana

APPLICATION FOR BOXER LICENSE OR RENEWAL OF LICENSE
State Form 45727 (R3 / 4-07) Approved by State Board of Accounts, 2007

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STATE BOXING COMMISSION PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it. 25-9-1-10 Persons not entitled to licenses and permits. No permit or license may be issued to any person who has not complied with this chapter or who, prior to the applications, has failed to obey a rule, regulation or order of the State Boxing Commission. In the case of a club, corporation, or association, no license or permit may be issued to it if, prior to its application, any of its officers have violated this chapter or any rule, regulation or order of the State Boxing Commission. No promoters, physicians, referees, judges, timekeepers, matchmakers, or professional boxers, their managers, trainers or seconds may be licensed if they are holders of a federal gambling stamp. A license or permit when issued shall recite that the person to whom it is granted has complied with this chapter, and a license or permit is not transferable. This application must be verified under oath of the applicant. No assumed or ring names shall be used in any application nor in any advertisement of any such contest, unless such ring or assumed name has been registered with the commission with the correct name of applicant. (Each application for license by a contestant, or for renewal thereof, must be accompanied by the certificate of a physician residing within the state, who has been licensed as herein provided, certifying that such physician has made a thorough physical examination of the applicant, and that the applicant is physically fit and qualified to participate in boxing or sparring matches or exhibition.)

FOR OFFICE USE ONLY

RECEIPT NUMBER APPLICANT LICENSE NUMBER DATE ISSUED (month, day, year) DATE EXPIRES (month, day, year) DO NOT WRITE ABOVE THIS LINE
Type of license (please check one)

Attach two (2) photographs of yourself.

Original license

Renewal License APPLICANT SECTION

Full name of applicant (please print) Residence address (number and street, city, state, and ZIP code) Residence telephone number Business telephone number

Ring name (please print)

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E-mail address Place of birth (city, state) Height

Social Security number * Normal weight

Date of birth (month, day year) Ring weight

Have you ever had a license revoked or suspended by a city or state boxing commission? (If yes, specify date and location)

Yes Yes Yes Yes

No No No No

Are you now licensed or have you been issued a license by any city or state boxing commission? (If yes, specify date and location) Have you been knocked out or severely beaten in the past sixty (60) days? Have you ever been convicted of a felony? (If yes, specify date, location and full details on a separate sheet of paper.) If license is issued to you under this application, do you promise and agree to faithfully and honestly observe and obey the laws of the state of Indiana and the statutes and rules of the State Boxing Commission relative to boxing or sparring matches or exhibitions and do you specifically agree that you will not engage in any boxing or sparring matches or exhibitions for any person or corporation other than a promoter duly licensed by the State Boxing Commission under the statutes and rules of the state of Indiana?

Yes

No

Do you clearly understand that any violation of the laws of the state of Indiana and / or the statutes and rules of the State Boxing Commission and / or of the promises and agreements made by you in this application contained may result in the suspension or revocation of any license issued to you hereunder?

Yes

No AFFIRMATION

I affirm under the penalties of perjury, that the statements made in this application are true and correct to the best of my knowledge.
Signature of applicant Printed name of applicant Date (month, day, year)