Free 45723.FH11 - Indiana

APPLICATION FOR PHYSICIAN LICENSE OR RENEWAL OF LICENSE FOR BOXING MATCHES
State Form 45723 (R2 / 7-07) 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) PREVIOUS LICENSE NUMBER DO NOT WRITE ABOVE THIS LINE
Type of application (please check one)

APPLICANT Attach two (2) photographs of yourself.

Original license

Renewal License APPLICANT SECTION

Name of applicant Residence address (number and street, city, state, and ZIP code) Residence telephone number Business telephone number

Social Security number *

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E-mail address

Business address (number and street, city, state, and ZIP code) Indiana medical license number

List five (5) references: NAME ADDRESS TELEPHONE NUMBER

SIGNATURE AFFIRMATION The undersigned has knowledge of the laws and rules regarding boxing or sparring matches or exhibitions in Indiana and will faithfully abide by them and attests that this application is true and accurate.
Signature of applicant Date (month, day, year)