Free 45729.FH11 - Indiana

APPLICATION FOR LICENSE OR RENEWAL OF LICENSE FOR TRAINER, MANAGER, MATCHMAKER, OR SECOND
State Form 45729 (R5 / 4-07) Approved by State Board of Accounts, 2007

Reset Form

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 application, 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.

FOR OFFICE USE ONLY

RECEIPT NUMBER LICENSE NUMBER DATE ISSUED (month, day, year) DATE EXPIRES (month, day, year) PREVIOUS LICENSE DO NOT WRITE ABOVE THIS LINE
Application for license (check one) Type of license (check appropriate box)

APPLICANT Attach one (1) photograph of yourself.

Original license

Renewal License

Trainer

Second APPLICANT SECTION

Manager

Matchmaker

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

Social Security number *

Date of birth (month, day year)

(

)

(

)

E-mail address

State your experience and qualifications

Are you a professional boxer?

If yes, ring name:

Yes Yes No

No

Was any boxer under your management or training ever disqualified in a ring of any cause? If Yes, state circumstances:

Are you employed by, or have you a financial interest in any promoter, club, corporation, association or organization conducting boxing matches in this state, or any other state?

Yes

No

List any boxers now under your management, training, or control or who will be seconded by you, or with whom you are associated, whether or not under contract. NAME WEIGHT UNDER CONTRACT

CERTIFICATION I hereby certify that I have knowledge of the laws, rules and regulations regarding boxing or sparring matches or exhibitions in Indiana and will faithfully abide by them; that I personally completed this application, and that the answers are true and correct to the best of my knowledge and belief; and have not disobeyed any rule, regulation or order of the State Boxing Commission or have not been guilty of any violation of the provisions of IC 25-9-1.
Signature of applicant Printed name of applicant Date (month, day, year)