Tdlr Form Box021 PDF Details

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QuestionAnswer
Form NameTdlr Form Box021
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestexas boxing commission, texas boxing license application, boxing license application, pro boxing license in texas

Form Preview Example

TEXAS DEPARTMENT OF LICENSING AND REGULATION

Compliance Division/COMBATIVE SPORTS PROGRAM

P.O. Box 12157 Austin, Texas 78711 (512)463-5101 - (800)803-9202 FAX (512)463-1087

E.O. Thompson Building, 920 Colorado, Austin, TX 78701

Email Address: boxing@license.state.tx.us Internet Address: www.license.state.tx.us

CONTESTANT IDENTIFICATION CARD APPLICATION

APPLICATION FEE $20.00

CHECK OR MONEY ORDER ONLY

FOR OFFICE USE ONLY

FEDERAL / NATIONAL ID#__________________________________

EXPIRATION DATE: ________________________________________

New _______ Renew _______ Reissue _______

All applications must be completed, signed and submitted with application fee and two passport photos.

FULL NAME:

RING NAME:

PLACE OF BIRTH:

 

 

 

 

 

 

 

 

DATE OF BIRTH:

 

 

 

 

 

TELEPHONE #:

 

 

 

 

 

 

 

 

SOCIAL SECURITY #:

 

 

 

 

STREET ADDRESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY:

 

 

 

 

STATE:

 

 

 

COUNTRY:

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

**E-MAIL ______________________________________________ HEIGHT:

 

WEIGHT:

 

HAIR COLOR:

 

 

EYE COLOR:

 

 

STANCE: RIGHT: ______________ LEFT: ________________

DISTINGUISHING CHARACTERISTICS (scars, tattoos, etc.):

TERMS & CONDITIONS

As per the Muhammad Ali Boxing Reform Act (federal law), each commission must present to every professional boxer/contestant a medical disclosure upon issuance of a Federal Identification Card.

As a professional boxer/contestant you should be aware that this sport includes many health and safety risks, particularly the risk of brain injury. Therefore, it is strongly recommended that a professional boxer/contestant undergo the necessary medical exams that detect brain injury. If you need further information about these exams, please contact your local boxing commission.

I solemnly affirm that the statements made on this application are true and the photographs attached are a true likeness of me. By signing this application, I agree to be bound by the rules and regulations of the American Boxing Commissioners and Combative Sports Program of the T.D.L.R. and the State of Texas. I understand if I have made a false or misleading statement, my license can be suspended or revoked.

SignatureDate

**The Department will add your address to the Combative Sports email notification list, which automatically provides information from the Department on matters affecting Combative Sports. Your email address is confidential pursuant to the Texas Public Information Act and the

Department will not share it with the public. See additional information at the following link:

http://www.license.state.tx.us/newsletters/TDLRnotificationLists.asp.

TDLR Form BOX021 1-09

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