AMATEUR FIGHTER CONFIRMATION FORM
ALL LINES ARE REQUIRED
FIGHTER INFORMATION:
NAME AS IT APPEARS ON ID CARD:_________________________________
ANY OTHER NAME(s) USED: _______________________________________
DRIVERS LICENSE NUMBER ___________________________ STATE:_____
DATE OF BIRTH: _____/_____/19___
HEIGHT: _________ WEIGHT: __________
ADDRESS: include city, state, and zip:
________________________________
________________________________
________________________________
PHONE NUMBER: (_____)________________________________
AMATEUR FIGHT RECORD:
MMA: W:_____ L_____ D:_____
KICKBOXING: W:_____ L_____ D:_____
BOXING: W:_____ L_____ D:_____
TRAINERS INFORMATION: NAME:____________________________________
CONTACT NUMBER: (_____)______________
PROMOTION NAME: __________________________________________
EVENT LOCATION: ___________________________________________
DATE OF EVENT: ____/_____/20_____
OPPONENT: __________________________ WEIGHT:______________
This is a Legal Amateur Status Confirmation Form binding The fighter named
above, Combat Sports Commission, The Promoter named above
and any and all of these companies, federations, organizations, associates,
officials, employees, and staff related to the fighter and event named above.
You hereby consent and agree to completely accept alone any and all Fines,
Suspensions and Disciplinary Actions if it is discovered that you are found to be
untruthful on ANY of the Questions below.
You must verify and confirm all of the below statements by placing your initials at
each item as well as signing your full and legal name below.
BE SURE READ THIS CAREFULLY.
________ - Voluntary Application. I, the undersigned, acknowledge and state
that I have ACCEPTED to compete in the EVENT NAMED ABOVE on the DATE LISTED
ABOVE as an AMATEUR Fighter.
I confirm under the penalty of perjury that; as of the EVENT DATE ;
I have Never been Paid, Contracted or Fought as a Professional in ANY of the following;
________ Mixed Martial Arts Fighter
. ________ Kickboxer.
________ Boxer.
________ ANY Full Contact Fight Sport.
PENALTY, FINES & SUSPENSIONS FOR PRO FIGHTERS FIGHTING AS AN AMATEUR
________ - I understand that if I have not been truthful with any of the above
questions that I will be responsible for the following disciplinary
actions:
________ - Fined $1,000.00 by the Board of Directors of CSC.
________ - Suspended for a minimum of 60 days up to 12 months.
________ - Infraction will be forwarded to the Office of Athletics.
________ - An incident report will be forwarded to the Prosecuting
Attorneys office having jurisdiction for possible criminal charges.
________ - In addition, my Trainer listed above may possibly face the
following disciplinary actions:
________ - Fined $1,000.00.
________ - Suspended for a minimum of 60 days up to 12 months.
________ - I agree that this Amateur Status Confirmation will be interpreted under and
construed in accordance with the Rules and Regulations instituted by Combat
Sports Commission and approved by the Missouri State Office of Athletics, and
the definition of a Professional Fighter and Amateur Fighter as follows:
AMATEUR DEFINITION: One who engages in an activity as a pastime rather than a professional; one
who lacks expertise.
AMATEUR IN SPORTS: An athlete who has never participated in competition for money. An athlete who
is not paid for his/her performance. An athlete at the beginning learning levels of his/her career.
PROFESSIONAL DEFINITION: Performed by persons receiving pay. An expert in a field of endeavor.
PROFESSIONAL IN SPORTS: An athlete who is paid for his/her performance. Paid for their excellence of
experience, knowledge and ability of their given sport. An athlete who receives any compensation for their
participation.
________ - Voluntary Execution. I hereby declare that I have
read this Amateur Status Confirmation Form in full and that I fully understand
the meaning and importance of its contents. I acknowledge that this Amateur
Status Confirmation Form is a binding confirmation between myself, Combat
Sports Commission, and the Promoter named above and any and all of these
companies, federations or organizations associates, officials, employees and
staff.
________ - Voluntary Execution. I further declare and represent
that I am at least 18 years of age, that I have full legal capacity to be bound by
this Amateur Status Confirmation Form, and that I am signing this Amateur
Status Confirmation Form of my own free will and accord.
KO - TKO - INJURY SUSPENSIONS
Have you ever suffered any knockouts (KO's), technical knockout's (TKO's),
or any kind of loss of consciousness in the last 30 DAYS prior to the date
of this event during a bout, sparring or in any other activity?
_____YES_____NO
If yes, please list and give dates and details: ____________________________________________________________
________ - I am not under any Medical Suspension by any Sanctioning body,
boxing or Athletic Commission or Medical supervisor of any kind.
________ - I am not under any Disciplinary Suspension by any Sanctioning
body, boxing or Athletic Commission or Medical supervisor of any kind.
________ - I have not been Knocked Out, had my fight stopped due to
excessive blows or sustained any head injuries that may have caused loss of
consciousness within the last 30 days.
FEMALES ONLY:
Are you pregnant? _____YES - _____NO
Pregnancy Advisory Notice:
If you participate in combative sports when you are pregnant you could have a miscarriage or you and or your fetus could suffer
permanent injury or death. Combat Sports Commission cannot force you to have a pregnancy test as a requirement for licensing or
before a bout. However, we strongly urge you to be tested before each of your bouts. We also, strongly urge you not compete if
you know or think you may be pregnant. Through this notice Combat Sports Commission is informing you that Combat Sports
Commission or any of its agents and the physician who conducts your pre-bout examination(s) are not
responsible for any injury that you and or your fetus suffers if you compete when you are pregnant.
I, (PRINT NAME) _________________________________________________________,
declare under the penalty of perjury; that under the rules and regulations of Combat Sports Commission; the foregoing information is
true and correct; I realize that any intentional misrepresentation may result in disciplinary action against me.
Executed in the City & State as listed above on the ______ day of the month of
_________________ , in the year 20____.
FIGHTER Signature: _______________________________
Print Name:_______________________________________
This form is based off of, and modified from a like form distributed and used by The International Sport Combat Federation.