APPLICATION FOR LICENCE AS A TRAINER,
MATCH-MAKER, REFEREE, JUDGE OR
TIMEKEEPER
Form 3 as per regulation 7, Professional Boxing and Combat Sports
I apply for a licence, or renewal of licence as a professional boxing and combat sports:
X
Trainer
X
Match-maker
X
Referee
X
Judge
X
Timekeeper
Name:
Email:
Telephone:
Postal Address:
Date of birth:
Q1. Have you previously been licensed, in Victoria or elsewhere as a:
Promoter
Referee
Judge
Match-maker
Timekeeper
Trainer
Yes
Yes
Yes
Yes
Yes
Yes
X
X
X
X
X
X
No
No
No
No
No
No
X
X
X
X
X
X
If “Yes” please provide details:
Q2. Are there any matters the Board should consider for the purposes of determining whether you are a fit and
proper person?
Yes X
No X
If “Yes” please provide details:
If applying for a Match-maker’s licence:
Q3. Have you ever competed as an amateur or professional boxer or combat sports contestant?
Yes X
No X
If “Yes” please give details of your experience:
Q4. Please provide details of your experience as a promoter or trainer:
If applying for a Trainer’s licence:
Q5. Do you have your own gymnasium or dojo?
If “Yes” give name and street address:
Q6. I have attached a current First Aid certificate.
Yes X
No X
Yes X
No X
Please turn over to complete form
If applying for a licence as a Judge, a Referee or a Timekeeper:
Yes X
Q7. Do you possess adequate vision?
No X
Q8. Do you wear glasses or contact lenses to correct any problems
with your eyesight?
Yes X
No X
Details:
This information is collected for the purpose of determining suitability for the role identified, thereby maintaining
the integrity of promotions and protecting the health and safety of contestants.
To be completed by all applicants:
Q9. Do you consent to the Board providing your contact details to other
licensed individuals for the purposes of organising professional
boxing and combat sports promotions?
Yes X
No X
X
I agree to be bound by the conditions attached to this licence, if approved.
X
I enclose evidence of my identity (such as a certified copy of my driver’s licence or other
government-issued photographic identification).
X
I attach a National Police Certificate.
The attached National Police Certificate should be issued no more than 3 months earlier than the date of this application.
Date:
Signature:
/
/
Applicants may be required to submit such additional information as is considered necessary for the issue of a licence.
Under section 6 of the Professional Boxing and Combat Sports Act 1985, before issuing a licence to an applicant to act as a trainer, match-maker, referee, judge or
timekeeper, the Board must be satisfied that the applicant is a fit and proper person to hold such a licence and that it is not contrary to the public interest to issue or
renew the licence.
A copy of this application will be given to the Chief Commissioner of Police under section 6A of the Professional Boxing and Combat
Sports Act 1985. A licence to act as a referee also authorises that person to act as a judge or a timekeeper.
A licence to act as a judge also authorises that person to act as a timekeeper.
Licence fees:
Payable by:
X Trainer:
$102.00
X Cheque
X Match-maker:
$490.00
X Money order
X Referee:
$102.00 Includes Judge licence
X Credit card / Debit card
X Judge:
X Timekeeper:
fee
$102.00
Note: Cash payments are not accepted.
$102.00
OFFICE USE ONLY
If payingreceived:
by credit
Payment
card or debit card,
please
enter payment
below:
Typedetails
of
Receipt
#:
Name on card:
Date
approved:
Card number:
Approved
by:
Signature
of cardholder:
identification:
Expiry: M M Y Y CCV:
All relevant documentation
attached:
X