Free 13255.FH11 - Indiana

APPLICATION FOR PERMIT TO HOLD A PARTICULAR BOXING OR SPARRING MATCH OR EXHIBITION
State Form 13255 (R4 / 5-07)

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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]

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. APPLICATION RECORD
Promoter's annual license number Permit number

Date issued (month, day, year)

Liability insurance company

Expires

Date applied (month, day, year)

As a licensed promoter the undersigned hereby makes application for permit to conduct a boxing or sparring match or exhibition in accordance with the provisions of IC 25-9-1, and hereby agrees to comply with said law and all the rules and regulations of the State Boxing Commission.
Name of promoter E-mail address

Address (number and street, city, state, and ZIP code)

Business telephone number

(
Name of agent at show

)

Name of physician at show

Name of ambulance service

PREMISES
Name of premises where contest or exhibition will be held

Address (number and street, city, state, and ZIP code)

Telephone number

(
Seating capacity Fire exits Ventilation

)

Proposed date of exhibition (month, day, year)

Days of the week

Time doors or gates open

Starting time

Complete price range of all tickets

Signature of applicant

Printed name of applicant

Date (month, day, year)

(Page 1 or 2)

MAIN EVENT RED
Name Ring name Purse and / or percentage Name of manager Weight License number NUMBER Name OF ROUNDS Ring name Purse and / or percentage

BLUE
License number

Weight

VERSUS

Name of manager

BALANCE OF CARD AS FOLLOWS: RED
Name Ring name Purse and / or percentage Name of manager Name Ring name Purse and / or percentage Name of manager Name Ring name Purse and / or percentage Name of manager Name Ring name Purse and / or percentage Name of manager Name Ring name Purse and / or percentage Name of manager Name Ring name Purse and / or percentage Name of manager Name Ring name Purse and / or percentage Name of manager Weight License number Weight License number Weight License number Weight License number Weight License number Weight License number Weight License number NUMBER Name OF ROUNDS Ring name Purse and / or percentage

BLUE
License number

Weight

VERSUS

Name of manager License number

NUMBER Name OF ROUNDS Ring name Purse and / or percentage

Weight

VERSUS

Name of manager License number

NUMBER Name OF ROUNDS Ring name Purse and / or percentage

Weight

VERSUS

Name of manager License number

NUMBER Name OF ROUNDS Ring name Purse and / or percentage

Weight

VERSUS

Name of manager License number

NUMBER Name OF ROUNDS Ring name Purse and / or percentage

Weight

VERSUS

Name of manager License number

NUMBER Name OF ROUNDS Ring name Purse and / or percentage

Weight

VERSUS

Name of manager License number

NUMBER Name OF ROUNDS Ring name Purse and / or percentage

Weight

VERSUS

Name of manager

(If more space is needed, attach on plain paper)

(Page 2 or 2)