AMATEUR FIGHTER CONFIRMATION RENEWAL FORM
ALL LINES ARE REQUIRED
FIGHTER INFORMATION:
FULL NAME :_____________________________________________
DRIVERS LICENSE NUMBER ______________________________ STATE:_____
DATE OF BIRTH: _____/_____/19___
ADDRESS: include city, state, and zip:
______________________________
______________________________
______________________________
PHONE NUMBER: (_____)________________________________
AMATEUR FIGHT RECORD:
MMA: W:_____ L_____ D:_____
KICKBOXING: W:_____ L_____ D:_____
BOXING: W:_____ L_____ D:_____
EVENT LOCATION: ___________________________________________
DATE OF EVENT: ____/_____/20_____
OPPONENT: _________________________________________________
This is a Legal Amateur Status Confirmation RENEWAL 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 certify that your status as an amateur fighter has not changed since your last declaration; and Furthermore; 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 this confirmation renewal.
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.
FIGHTER Signature: _______________________________
Print Name:_______________________________________
ALL LINES ARE REQUIRED
FIGHTER INFORMATION:
FULL NAME :_____________________________________________
DRIVERS LICENSE NUMBER ______________________________ STATE:_____
DATE OF BIRTH: _____/_____/19___
ADDRESS: include city, state, and zip:
______________________________
______________________________
______________________________
PHONE NUMBER: (_____)________________________________
AMATEUR FIGHT RECORD:
MMA: W:_____ L_____ D:_____
KICKBOXING: W:_____ L_____ D:_____
BOXING: W:_____ L_____ D:_____
EVENT LOCATION: ___________________________________________
DATE OF EVENT: ____/_____/20_____
OPPONENT: _________________________________________________
This is a Legal Amateur Status Confirmation RENEWAL 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 certify that your status as an amateur fighter has not changed since your last declaration; and Furthermore; 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 this confirmation renewal.
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.
FIGHTER Signature: _______________________________
Print Name:_______________________________________
