Free 45728.FH11 - Indiana

APPLICATION FOR LICENSE OR RENEWAL OF LICENSE: REFEREE, JUDGE, TIMEKEEPER
State Form 45728 (R4 / 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. Social Security numbers are available to the Indiana Department of Revenue. 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.

FOR OFFICE USE ONLY

RECEIPT NUMBER LICENSE NUMBER DATE ISSUED (month, day, year) DATE EXPIRES (month, day, year) 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

Referee

Judge

Timekeeper

REFEREE APPLICATIONS MUST BE ACCOMPANIED BY CERTIFIED PHYSICAL EXAMINATION BY APPROVED PHYSICIAN APPLICANT SECTION
Full name of applicant (first, middle, last) (please print) Address (number and street, city, state, and ZIP code) Home telephone number Business telephone number E-mail address Social Security number * Date of birth (month, day year)

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Identification will be verified by one (1) of the following:

Birth certificate

Baptismal certificate

Driver's license

School record

Passport

State your experience and qualifications:

List clubs or associations that you officiated: NAME OF CLUBS OR ASSOCIATIONS ADDRESS OF CLUBS OR ASSOCIATIONS REFERENCE

List three (3) references other than those stated previously: NAME ADDRESS

CERTIFICATION (Continued on reverse side)

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)

COMMISSION APPROVAL