Free 45726.FH11 - Indiana

APPLICATION FOR PROMOTERS LICENSE TO HOLD BOXING OR SPARRING MATCHES OR EXHIBITIONS
State Form 45726 (R4 / 5-07) 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) DO NOT WRITE ABOVE THIS LINE
Type of license (please check one)

APPLICANT Attach one (1) photograph of yourself.

Original license

Renewal License APPLICANT SECTION

Name of applicant (individual (first, middle,and last), company or organization) (please print) Address of applicants principal business (number and street, city, state, and ZIP code) Telephone number E-mail address

Social Security or Federal identification number*

(

)

Date of incorporation (month, day, year) (if applicable) (attach a certified copy of articles of incorporation) Name of director (if any)

Name of matchmaker (if any)

Is any promoter, manager, booker, boxer, other person connected with boxing interested in applicant either as partner, stockholder, member, bondholder, mortgagee or in any other capacity, directly or indirectly? If Yes, please explain:

Yes

No

Is any manager or boxer employed by applicant? If Yes, please explain:

Yes

No

Has applicant been denied a promoters license in Indiana or in any state, or had license revoked or suspended in any state? If Yes, please explain:

Yes

No

Does applicant have a Federal Gambling Stamp?

Has applicant ever held a Federal Gambling Stamp?

Yes Yes

No No

Yes

No

Has applicant, or any of its stockholders, officers or members, any financial interest in boxers? If license under this application is granted, does undersigned promise and agree to faithfully observe, enforce and obey the laws of the State of Indiana , and the rules of the State Boxing Commission relating to the conduct of boxing or sparring matches or exhibitions?

Yes

No

(Continued on reverse side)

List five (5) references: NAME ADDRESS (number and street, city, state, and ZIP code) TELEPHONE NUMBER

CERTIFICATION I have executed the foregoing application and that the questions and answers set forth in the foregoing application are true and correct to the best of my knowledge and belief; and that I have not disobeyed any rule, regulation or order of the State Boxing Commission or been guilty of any violation of the provisions of IC 25-9-1.
Signature of applicant Printed name of applicant Date (month, day, year)