Tdlr Form Box001 – Fill Out and Use This PDF

TEXAS DEPARTMENT OF LICENSING AND REGULATION

P.O. Box 12157 - Austin, Texas 78711-2157

1-800-803-9202 - (512) 463-5101 - FAX (512) 463-1087 www.tdlr.texas.gov - Combative.Sports@tdlr.texas.gov

COMBATIVE SPORTS PROFESSIONAL CONTESTANT LICENSE APPLICATION

PURSUANT TO TITLE 13, OCCUPATIONS CODE, CHAPTER 2052

EVENT

FEE

PAYMENT

MONEY

RECEIPT NUMBER

CODE

AMOUNT

AMOUNT

TYPE

$20.00

All fees are non-refundable

DO NOT WRITE ABOVE THIS LINE

1.

Full Name:

Last Name

First Name

Middle name

2.

Mailing Address:

Number , Street, Suite No., Apt No or P. O. Box

City

State

Zip Code

3.

Phone Number:

4. Social Security No.

-

-

(

)

(Foreign Nationals may submit Passport #)

5.

Date of Birth:

6. Place of Birth:

-

-

___

7.

Female □

Male □

8. Email Address:

__

9.

Promoter Name:

10. Event Date:

_

/

/

I certify that all information is true and correct. I understand that providing false information on this application may result in sanctions up to and including denial or revocation of the license I am requesting, and in the imposi- tion of the administrative penalties. I will comply with all applicable provisions of Chapters 51 and 2052, Texas Occupations Code, and 16 Texas administrative Code, Chapters 60 and 61. I understand that this license is not transferable. If the license is issued, I agree to furnish to the Texas Department of Licensing and Regulation any change in information provided on this form within Thirty (30) days of the change.

Applicant Signature

Date

TDLR FORM BOX001 REVISED 08/2013

APPLICANT NAME (Please print) _____________________________

PROFESSIONAL CONTESTANT'S MEDICAL EXAMINATION - PART 1

TO BE COMPLETED BY A LICENSED MEDICAL DOCTOR ONLY

Forms completed by a physician assistant or a nurse practitioner will NOT be accepted

Medical Allergies ______________________________________________________________________

Are you taking any medication? __ YES __ NO; EXPLAIN _____________________________________

Previous Hospitalization(s) or surgery (Give dates) ______________________________________________

Results of the following blood tests must be attached to this application:

□Hepatitis B surface ANTIGEN

□Hepatitis C ANTIBODY

□HIV ANTIBODY

ALL MEDICAL AND LAB TEST RESULTS MUST BE DATED AND TAKEN

WITHIN THE LAST 6 MONTHS BEFORE THE APPLICATION IS SUBMITTED.

Answer All Questions Below (circle each answer)
(A) BLEEDING TENDENCIES	YES	NO	(L) SEIZURES AND CONVULSIONS	YES	NO
(B) DIABETES	YES	NO	(M) ASTHMA	YES	NO
(C) HERNIA	YES	NO	(N) HIGH BLOOD PRESSURE	YES	NO
(D) HEART DISEASE	YES	NO	(O) TUBERCULOSIS	YES	NO
(E) SICKLE CELL DISEASE	YES	NO	(P) MONONUCLEOSIS	YES	NO
(F) KIDNEY DISEASE	YES	NO	(Q) RHEUMATIC FEVER	YES	NO
(G) HEPATITIS	YES	NO	(R) COUGH	YES	NO
(H) SKIN DISEASE	YES	NO	(S) PSYCHIATRIC PROBLEMS	YES	NO
(I) HEADACHES	YES	NO	(T) CONTACT LENSES	YES	NO
(J) JOINT INJURY OR DISLOCATION	YES	NO	(U) NUMBER OF TIMES KO'D	_______
(K) CONCUSSION/UNCONSCIOUSNESS	YES	NO	(V) KIDNEY, LUNG, TESTICLE, EYE REMOVED	YES	NO

Do you have any other information concerning your health, past or present, which is NOT COVERED

by the questions above? __________________________________________________________________________________

A PERSON AGE 36 OR OLDER MUST ALSO SUBMIT A FAVORABLE:

EEG (Electroencephalography) AND

EKG (Electrocardiogram)

EXAMINING MD or DO NAME (Please print) _______________________________________________

MEDICAL LICENSE # __________________________________________________________________

(must be licensed in a State, District or Territory of the United States)

ADDRESS _________________________________________________ CITY _______________________

STATE ____________ ZIP ____________ PHONE NUMBER ____________________________________

MD or DO SIGNATURE ________________________________________ DATE ___________________

APPLICANT SIGNATURE	_____ DATE			___
APPLICANT NAME (Please Print)________________________________

TDLR FORM BOX001 REVISED 08/2013

PROFESSIONAL CONTESTANT'S MEDICAL EXAMINATION - PART 2

EARS

AUDITORY CANALS	RIGHT _____ LEFT _______
DRUMS	RIGHT _____ LEFT _______
AUDITORY ACUITY FOR CONVERSATIONAL VOICE	RIGHT _____ LEFT _______

NOSE (note deformity, old fractures, deviated septum, other)

__________________________________________________________________

OROPHARYNX

TONSILS ________________ GUM ___________________ TEETH __________________________

TONGUE (record any deviation or tremors) ____________________________________________

NECK (note masses, pulse, thyroid, carotid, bruits, and limitation of motion)

THORAX

LUNGS __________________________________________________________________________

HEART (size, murmurs, arrhythmia) __________________________________________________

HEART RATE ______________________ BLOOD PRESSURE (S) __________ (D) _____________

PULSE RATE _______________________ IMMEDIATELY AFTER 20 HOPS __________________

2 MINUTES AFTER EXERCISE _____________________________________________________________

ABDOMEN

NOTE SCARS _____________________________________________________________________

LIVER, KIDNEY, SPLEEN (enlarged, tender) ___________________________________________

INGUINAL AREA (tenderness, hernia) ________________________________________________

SKIN (note staph infection, cyanosis, hair distribtion____________________________________

LYMPHATIC SYSTEM ___________________________________________________________________

MUSCULOSKELETAL SPINAL SYSTEM (curvature, posture, tenderness, limitation of motion)

__________________________________________________________________

EXTREMITIES (deformity, tenderness, joint mobility) __________________________________________

NEUROLOGICAL

GAIT ________________________________ RHOMBERG ________________________________

FINGER TO NOSE _____________________ KNEE JERKS _______________________________

BICEP JERKS _________________________ BABINSKI __________________________________

BRUDZINSKI _________________________ CRANIAL NERVES __________________________

I hereby certify that I have examined ______________________________________________

(please print applicant’s name)

Date of the exam: ________________ , ________________ ________________

MonthDay Year

I HAVE APPROVED THIS PERSON TO PARTICIPATE IN A COMBATIVE SPORTS EVENT.

MD or DO SIGNATURE ________________________________________ DATE ___________________

APPLICANT SIGNATURE _______________________________________ DATE ___________________

TDLR FORM BOX001 REVISED 08/2013

APPLICANT NAME (Please Print)_________________________

** OPHTHALMOLOGIC MEDICAL EXAM **

Exam with dilation must be done by an OPHTHALMOLOGIST or OPTOMETRIST

EXAMINATION (normal – N; abnormal - X)	RIGHT EYE	LEFT EYE
VISUAL ACUITY	N _________	N ________
(WITHOUT CORRECTION)
	F _________	F ________
EXTERIOR EXAM	_________	________
ANTERIOR EXAM	_________	________
FUNDI	_________	________
EXTRAOCULAR MUSCLES	_________	________
VISUAL FIELDS (Confrontation)	_________	________
TONOMETRY	__________	_________

EXPLAIN ABNORMAL FINDINGS

___________________________________________________________________________

DIAGNOSIS ________________________________________________________________________

____________________________________________________________________________________

I hereby certify that a dilated exam was performed on:_________________________________________

		(please print applicant’s name)
Date of the exam: ________________ , ________________ ________________
Month	Day	Year

I HAVE APPROVED THIS PERSON TO PARTICIPATE IN A COMBATIVE SPORTS EVENT.

Ophthalmologist or Optometrist NAME ____________________________________________________

(please print)

LICENSE # _____________________________________________________________________________

(must be licensed in a State, District or Territory of the United States)

ADDRESS _________________________________________________ CITY _______________________

STATE ____________ ZIP ____________ PHONE NUMBER ____________________________________

OPHTHAMOLOGIST or

OPTOMETRIST SIGNATURE _______________________________________ DATE _______________

APPLICANT SIGNATURE _______________________________________ DATE __________________

TDLR FORM BOX001 REVISED 08/2013