MMA/Boxing Officials License Application

MMA/Boxing Officials License Application

Download PDF Version Here OR fill out the form below

Next Event Date:

Full Name (First Middle Last):

Date Of Birth (Month/Day/Year):

Current Street Address:

City, State, Zip, Country:

Home Phone:

Cell Phone:

Email:

This is the only name I have used to become licensed: Yes No

Other Name:

Which official are being licensed for?

Are you also an MMA combatant: Yes No

If yes, you must complete the "Combatant/Boxing License Application."

Minnesota ID#:

Drivers License:

Number:
State:

I'm Licensed in these States:

Gym:

Name:
Phone:

Name of combatants you're training, coaching, or providing services for:

Experience:

I hereby certify that to the best of my knowledge and belief that the above statements are true and correct. I also realize that any deliberate misstatement will subject my license to disciplinary action by the MN Combative Sports Commission.

Mail two passport size photos, copy of blood work and a $25 check made payable to MN Combative Sports Commission to: MN Boxing/MMA Commission, 358 139th Lane NW, Andover, MN 55304. Must be received at least 2 days prior to event. If you have any questions contact us.

Please Initial and Date:

Initial:
Date:

The State of Minnesota, in compliance with Statute 13.41 Licensing Data, views all information submitted by any applicant for any license to be public.