Form Pa 611 028 PDF Details

Form Pa 611 028 is a request for an exemption to the mandatory helmet law. The form can be used by any Pennsylvania resident who wants to ride a motorcycle without a helmet. There are certain requirements that must be met in order to be approved for the exemption, so it's important to understand what they are before submitting the form. This article will outline the requirements and provide instructions on how to complete and submit Form Pa 611 028.

QuestionAnswer
Form NameForm Pa 611 028
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesassessed, TTY, level 4 combatives, Certifying

Form Preview Example

Combative Sports Certification of Official

An individual wishing to be approved, or maintain his/her license, shall provide annual proof of certification as having adequate experience, skill, and training from an organization approved by the Department. (RCW 67.08.100)

When completed, send this form to:

Combative Sports Program, Department of Licensing, PO Box 9026, Olympia, WA 98507-9026 or fax to (360) 570-4956

I certify that I have assessed the experience and skill of

Name of individual

and this individual has adequate experience, skill, and training to be licensed in Washington State to perform in the following official capacity for professional or amateur combative sporting events.

Official capacity

Event type

Date training completed

Name of instructor

 

 

 

 

Referee

Pro boxing

 

 

 

 

 

 

 

Pro martial arts

 

 

 

 

 

 

 

Amateur mixed

 

 

 

martial arts

 

 

 

 

 

 

Judge

Pro boxing

 

 

 

 

 

 

 

Pro martial arts

 

 

 

 

 

 

 

Amateur mixed

 

 

 

martial arts

 

 

 

 

 

 

Timekeeper

Pro boxing

 

 

 

 

 

 

 

Pro martial arts

 

 

 

 

 

 

 

Amateur mixed

 

 

 

martial arts

 

 

 

 

 

 

Inspector

Pro boxing

 

 

 

 

 

 

 

Pro martial arts

 

 

 

 

 

 

 

Amateur mixed

 

 

 

martial arts

 

 

 

 

 

 

Describe in detail your assessment of the above individual’s skills, experience, and abilities to perform these duties, and provide specific examples:

PRINT or TYPE Certifying organization name

Address

City

State

ZIP Code

(Area code) Telephone number

PRINT or TYPE Name of authorized representative

Signature of authorized representative

X

Date

PA-611-028 (R/8/13)WA

We are committed to providing equal access to our services. If you need accommodation, please call (360) 664-6644 or TTY (360) 664-0116.

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Part number 1 of filling in Washington

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A way to prepare Washington part 2

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