I apply for a licence, or renewal of licence as a professional boxing and combat sports:

Trainer Match-maker Referee Judge Timekeeper

Name: Email:

Postal Address: Date of birth:

Q1. Have you previously been licensed, in Victoria or elsewhere as a:

Promoter Referee / Yes Yes / X X / No No / X X
Judge / Yes / X / No / X
Match-maker / Yes / X / No / X
Timekeeper / Yes / X / No / X
Trainer / Yes / X / No / 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 No

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 No

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:

Yes No

Q6. I have attached a current First Aid certificate. Yes No

Please turn over to complete form

If applying for a licence as a Judge, a Referee or a Timekeeper:

Q7. Do you possess adequate vision? Yes No

Q8. Do you wear glasses or contact lenses to correct any problems with your eyesight?

Details:


Yes No

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 No

I agree to be bound by the conditions attached to this licence, if approved.

I enclose evidence of my identity (such as a certified copy of my driver’s licence or other government-issued photographic identification).

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.

Signature: Date: / /

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:

X Match-maker:

X Referee:

X Judge:

X Timekeeper:


$100.00

$480.00

$100.00 Includes Judge licence fee

$100.00

$100.00


X Cheque

X Money order

X Credit card / Debit card

Note: Cash payments are not accepted.

If paying by credit card or debit card, please enter payment details below:

Name on card:
Card number: / Expiry: / M / M / Y / Y / CCV:

Signature of cardholder: