GEORGIA ATHLETIC COMMISSION LICENSE This license is valid for all fighters and trainers in Georgia for all combat sports licensed by the Georgia Athletic Commission! Type of License * Pro MMA / Kicboxing / Muay Thai Contestant Amateur MMA / Kickboxing / Muay Thai Contestant MMA / Kickboxing / Muay Thai Trainer / Second Pro Boxer Pro Boxing Trainer / Second Name * First Name Last Name Alias (other names used) * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date Of Birth * MM DD YYYY Social Security # * Height * Weight * Sex * Male Female Citizenship * Place Of Birth * Driver’s License # * State Issued * Are you presently on any suspension list? If yes, please explain * Have you ever been disqualified in any contest or disciplined for your actions during a Contest? If yes, please explain * Has any license you’ve had been revoked? If yes, please explain * List all other Athletic Commissions in which you are licensed * Have you ever been convicted of a crime, regardless of adjudication, or have charges pending? If yes, please explain * Boxing/ MMA Federal ID# (if you don't know it, just type 0) * Have you ever been hospitalized due to an injury suffered in any contest? If yes, please explain * Do you have any current medical conditions? If yes, please explain * Do you have a manager? If yes, provide name address and telephone number * Have you had amateur experience? If yes, complete the following questions * Jiu Jitsu Belt Color and Record or Accomplishments * Name of Gym you train at * Name and telephone number of Trainer * TRAINERS ONLY: List names of boxers and / or MMA contestants which you currently manage/train/second TRAINERS ONLY: Do you know of any medical conditions which your boxers and/or MMA contestants currently have? If YES, please explain List the names of any person under the jurisdiction of the Georgia Athletic and Entertainment Commission in whom you have a financial interest (if none, type none) * List the names of any persons who have a financial interest in you * I hereby swear and affirm that all information provided in this application is true and correct to the best of my knowledge and belief. I further swear and affirm that I have read and understand the current state laws and rules and regulations of the Georgia Athletic and Entertainment Commission and I agree to abide by these laws and rules, as amended from time to time. By signing this application, electronically of otherwise, I hereby swear and affirm one of the following to be true and accurate pursuant to O.C.G.A. § 50-36-1: * I am a United States citizen 18 years of age or older. I am not a United States citizen, but I am a legal permanent resident of the United States 18 years of age or older, or I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18 years of age or older with an alien number issued by the Department of Homeland Security or other federal immigration agency. I THE UNDERSIGNED DECLARE THAT I HAVE READ THIS APPLICATION AND THAT ALL THE ANSWERS TO THE QUESTIONS ARE TRUE AND COMPLETE, I UNDERSTAND THAT ANY MISREPRESENTATION OF FAILURE TO ANSWER SHALL CONSTITUTE GROUNDS FOR LICENSE REVOCATION AND OR OTHER APPLICABLE LEGAL PENALTIES I ALSO UNDERSTAND THAT BY SIGNING THIS APPLICATION THAT I AM AUTHORIZING THE GEORGIA ATHLETIC AND ENTERTAINMENT COMMISSION TO CONDUCT A FULL INVESTIGATION INTO MY BACKGROUND AND ACTIVITIES, I UNDERSTAND THAT THE OFFICE OF THE ATTORNEY GENERAL AND THE GEORGIA STATE POLICE MAY PARTICIPATE IN THE BACKGROUND INVESTIGATION. TO ALL COURTS, PROBATION DEPARTMENTS, SELECTIVE BOARDS, EMPLOYERS, EDUCATIONAL, INSTITUTIONS, FINANCIAL INSTITUTIONS AND ALL GOVERNMENT AGENCIES, FEDERAL, STATE, AND LOCAL, WITHOUT EXCEPTION, BOTH FOREIGN AND DOMESTIC. I HAVE APPLIED FOR A LICENSE WITH THE GEORGIA ATHLETIC AND ENTERTAINMENT COMMISSION AND FOR THE PURPOSE OF THIS APPLICATION, YOU ARE HEREBY AUTHORIZED TO RELEASE ANY AND ALL INFORMATION PERTAINING TO ME, DOCUMENTARY OR OTHERWISE, AS REQUESTED BY ANY APPROPRIATE EMPLOYEE, AGENT, OR REPRESENTATIVE OF THE GEORGIA ATHLETIC AND ENTERTAINMENT COMMISSION, THE OFFICE OF THE ATTORNEY GENERAL OR THE GEORGIA STATE POLICE I UNDERSTAND THAT A PHOTOSTATIC COPY OF THIS AUTHORIZATION WILL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL FURTHER, I AM AWARE AND AGREE THAT MY SIGNATURE CONSTITUTES A WAIVER OF LIABILITY AS TO THE STATE OF GEORGIA AND IT’S INSTRUMENTALITIES AND AGENTS FOR ANY DAMAGES RESLUTING IN DISCLOSURE OR PUBLICATION IN AN ANY MANNER OTHER THAN A WILLFULLY UNLAWFUL DISCLOSURE OR PUBLICATION OF ANY MATERIAL OR INFORMATION ACQUIRED DURING THE LICENSURE CONSIDERATION PROCESS OR DURING ANY INVESTIGATION, INQUIRY OR HEARING I HEREBY AUTHORIZE THE RELEASE OF ANY CRIMINAL HISTORY RECORD INFORMATION TO THIS AGENCY ONLY FOR THE EXPRESS PURPOSE OF PROCESSING MY APPLICATION FOR A LICENSE. I UNDERSTAND THAT THE DISCLOSURE OF MY SOCIAL SECURITY NUMBER ON THIS APPLICATION IS VOLUNTARY AND THAT IT WILL ONLY BE USED FOR PURPOSES OF PROCESSING MY APPLICATION * First Name Last Name By checking this box and typing my name below, I acknowledge that I understand and agree to electronically sign this document. I understand that my typed name will serve as my electronic signature, and I intend for it to have the same legal effect as a handwritten signature. * Understood Thank you for filling out your Georgia Athletic Commission fighter’s or trainer’s license. The next step is to pay the $35 for your license. The Athletic Commission fee is $30 and the NFC adds $5 to cover the online processing fees.Boxing licenes are valid Jan 1 - Dec 31. MMA and kickboxing licenses are valid July 1 - June 30.
