Form BPR-0009-450 "Application for License" - Florida

What Is Form BPR-0009-450?

This is a legal form that was released by the Florida State Boxing Commission - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the Florida State Boxing Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form BPR-0009-450 by clicking the link below or browse more documents and templates provided by the Florida State Boxing Commission.

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Download Form BPR-0009-450 "Application for License" - Florida

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F
S
B
C
LORIDA
TATE
OXING
OMMISSION
2601 Blair Stone Road,Tallahassee, Florida 32399 (850) 488-8500 fax (850) 922-2249
______________________________________________________________________________
A
L
PPLICATION FOR
ICENSE
Please check the box(s) for each license type for which you are applying. This form must be completed by any person applying for
any license listed below and all questions must be answered. If you need additional space to answer a question, please use a
separate sheet of paper. Application fees are non-refundable.
 Boxing
 Kickboxing
 Mixed Martial Arts
 Announcer $50
 Matchmaker $100
 Ringside Physician $0
 Participant $25
 Second $20
 Manager $100
 Promoter $250
 Timekeeper $50
 Trainer $20
 Judge $100
 Referee $100
SECTION 1. – TO BE COMPLETED BY ALL APPLICANTS (go to Section 4 next)
Date of Application: ______________________
Legal Name: _______________________________________________________________ Social Security Number*: _______________________
(Last)
(First)
(Middle)
Gender: MALE / FEMALE
Date of Birth: ________________
Home Address: ________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
(Country)
Telephone Number:
(
)
__
Ext.__________
E-Mail:_______________________________________
Participant Manager’s Name: ______________________________________
Participant Ring Name: ____________________________________________
SECTION 2. – TO BE COMPLETED BY MANAGER AND PROMOTER APPLICANTS (go to SECTION 4 next)
Check the appropriate box. You are applying for this license as a:
 Corporate officer or member of the corporation or limited liability company
 Partner of the partnership
 Individual
Doing Business As (name in which license is to be issued): _____________________________________________________________________
Business Address: ______________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Provide the name of each officer of the corporation, member of the limited liability company or partner of the partnership:
______________________________________________________________________________________________________________________
If you checked CORPORATION or LIMITED LIABILITY COMPANY above:
State in which incorporated / organized: ____________________
Date of incorporation / organization: ______________________________
Name of Resident Agent: __________________________________________ Telephone Number: ____________________________________
Address of Resident Agent: _______________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Manager: In the case of a corporation, each officer of the corporation must submit an application form. In the case of a limited liability company,
each member must submit an application. In the case of a partnership, each partner must submit an application form. The license fee will cover all
officers of a single corporation, members of a limited liability company or all partners of a single partnership. Only those officers, members or
partners who have filed applications with the commission will be permitted to negotiate or sign contracts for the corporation or partnership.
Promoter: In the case of a corporation, each officer of the corporation must submit an application form. In the case of a limited liability company,
each member must submit an application. In the case of a partnership, each partner must submit an application form. The license fee will cover all
officers of a single corporation, members of a limited liability company or all partners of a single partnership. A surety bond or other security
acceptable to the commission, in the amount of $15,000, must be filed with the commission prior to issuance of the license. The name of the
principal shown on the face of the surety bond, or in whose name the security has been issued, must be the same name in which the license is to be
issued. No person shall engage in any activity requiring licensure as a promoter until the bond or other security has been filed with the commission
and the license has been approved.
*
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number.
Disclosure of Social Security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 409.2577, 409.2598, and 559.797,
Florida Statutes. Social security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with
child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification
pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L. 193, Sec. 317. The State of Florida is
security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(l). This information is used to
authorized to collect the social
identify licensees for tax administration purposes.
BPR-0009-450
Rules 61K1-3.001 and 61K1-3.007
2015 September
F
S
B
C
LORIDA
TATE
OXING
OMMISSION
2601 Blair Stone Road,Tallahassee, Florida 32399 (850) 488-8500 fax (850) 922-2249
______________________________________________________________________________
A
L
PPLICATION FOR
ICENSE
Please check the box(s) for each license type for which you are applying. This form must be completed by any person applying for
any license listed below and all questions must be answered. If you need additional space to answer a question, please use a
separate sheet of paper. Application fees are non-refundable.
 Boxing
 Kickboxing
 Mixed Martial Arts
 Announcer $50
 Matchmaker $100
 Ringside Physician $0
 Participant $25
 Second $20
 Manager $100
 Promoter $250
 Timekeeper $50
 Trainer $20
 Judge $100
 Referee $100
SECTION 1. – TO BE COMPLETED BY ALL APPLICANTS (go to Section 4 next)
Date of Application: ______________________
Legal Name: _______________________________________________________________ Social Security Number*: _______________________
(Last)
(First)
(Middle)
Gender: MALE / FEMALE
Date of Birth: ________________
Home Address: ________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
(Country)
Telephone Number:
(
)
__
Ext.__________
E-Mail:_______________________________________
Participant Manager’s Name: ______________________________________
Participant Ring Name: ____________________________________________
SECTION 2. – TO BE COMPLETED BY MANAGER AND PROMOTER APPLICANTS (go to SECTION 4 next)
Check the appropriate box. You are applying for this license as a:
 Corporate officer or member of the corporation or limited liability company
 Partner of the partnership
 Individual
Doing Business As (name in which license is to be issued): _____________________________________________________________________
Business Address: ______________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Provide the name of each officer of the corporation, member of the limited liability company or partner of the partnership:
______________________________________________________________________________________________________________________
If you checked CORPORATION or LIMITED LIABILITY COMPANY above:
State in which incorporated / organized: ____________________
Date of incorporation / organization: ______________________________
Name of Resident Agent: __________________________________________ Telephone Number: ____________________________________
Address of Resident Agent: _______________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Manager: In the case of a corporation, each officer of the corporation must submit an application form. In the case of a limited liability company,
each member must submit an application. In the case of a partnership, each partner must submit an application form. The license fee will cover all
officers of a single corporation, members of a limited liability company or all partners of a single partnership. Only those officers, members or
partners who have filed applications with the commission will be permitted to negotiate or sign contracts for the corporation or partnership.
Promoter: In the case of a corporation, each officer of the corporation must submit an application form. In the case of a limited liability company,
each member must submit an application. In the case of a partnership, each partner must submit an application form. The license fee will cover all
officers of a single corporation, members of a limited liability company or all partners of a single partnership. A surety bond or other security
acceptable to the commission, in the amount of $15,000, must be filed with the commission prior to issuance of the license. The name of the
principal shown on the face of the surety bond, or in whose name the security has been issued, must be the same name in which the license is to be
issued. No person shall engage in any activity requiring licensure as a promoter until the bond or other security has been filed with the commission
and the license has been approved.
*
Under the Federal Privacy Act, disclosure of Social Security numbers is voluntary unless a Federal statute specifically requires it or allows states to collect the number.
Disclosure of Social Security numbers is mandatory pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 409.2577, 409.2598, and 559.797,
Florida Statutes. Social security numbers are used to allow efficient screening of applicants and licensees by a Title IV-D child support agency to assure compliance with
child support obligations. Social Security numbers must also be recorded on all professional and occupational license applications and are used for licensee identification
pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub.L. 193, Sec. 317. The State of Florida is
security number of licensees pursuant to the Social Security Act, 42 U.S.C. 405(c)(2)(C)(l). This information is used to
authorized to collect the social
identify licensees for tax administration purposes.
BPR-0009-450
Rules 61K1-3.001 and 61K1-3.007
2015 September
SECTION 3. – TO BE COMPLETED BY RINGSIDE PHYSICIAN APPLICANTS (go to SECTION 5 next)
You must be currently licensed under Chapter 458 or 459, Florida Statutes, in order to be eligible for this license. A ringside
physician may not have any interest in a participant. Please provide your Florida Department of Health License Number (if you do not have your
license number, please indicate under which board you are licensed):
_____________________________________
SECTION 4. – TO BE COMPLETED BY ALL APPLICANTS
If you are now or have ever been licensed by the Florida State Boxing Commission, another athletic commission or any similar governmental
authority, provide the following information for each license, listing the most recent first:
Type of License
Year license was issued
Indicate State or Other Commission/Government Authority
____________________
_____________________
______________________________________________________________
____________________
_____________________
______________________________________________________________
____________________
_____________________
______________________________________________________________
Has your license ever been suspended, revoked or fined by the Florida State Boxing Commission, another athletic commission or any similar
 Yes
 No
governmental authority?
If YES, provide the following information, listing the most recent action first. Attach an explanation.
Type of License
Action Taken
State in which action was taken
Date of Action
______________________
______________________________
______________________________
_____________________
______________________
______________________________
______________________________
_____________________
 Yes
 No
Are there charges pending against you by the Florida State Boxing Commission or any similar governmental authority?
If YES, provide the following information, listing the most recent charge first:
Charge
Date of Charge
Commission/Governmental Authority
Hearing Date
______________________
______________________
______________________________________
____________________
______________________
______________________
______________________________________
____________________
Have you been convicted of; pleaded guilty to, entered a plea of non contendere to, or have been found guilty of a crime involving moral turpitude in
 Yes
 No
any jurisdiction within the past 10 years?
If YES, provide the following information, listing the most recent conviction first:
Crime
Date of Conviction
City, State, Country
Status
______________________
______________________
______________________________
____________________________
______________________
______________________
______________________________
____________________________
SECTION 5. – TO BE COMPLETED BY PARTICIPANT, RINGSIDE PHYSICIAN, ANNOUNCER, MATCHMAKER, TIMEKEEPER, REFEREE,
TRAINER, JUDGE, SECOND APPLICANTS
List the names of any persons or business entities under the jurisdiction of the Florida State Boxing Commission in whom you have a financial
interest.
_______________________________________________
________________________________________________
_
SECTION 6. – TO BE COMPLETED BY PARTICIPANT APPLICANTS
List the names of any persons or business entities that have a financial interest in you.
________________________________________________________________
________________________________________________________________
SECTION 7. – TO BE COMPLETED BY ALL APPLICANTS
I have verified the answers to all questions on both sides of this application and do attest that answers given here are true and correct to the best of
my knowledge. I understand that if, for whatever reason, any item on either side of this form is not answered or is left blank, it will be presumed that
the item that was not answered or was left blank is not applicable or is answered in the negative, specifically “no” or “none”. I understand that if the
commission determines that I have knowingly made or implied any false statements, this application for license will be denied or if issued, the
license will be revoked. Further, the State of Florida may prosecute me and the entity named as the applicant for this license for a second-degree
misdemeanor and/or fine me and the entity named as the applicant for this license pursuant to S. 837.06, Florida Statutes.
I understand that this license, if approved, will expire on December 31 of the year in which it is effective..
______________________________
_______________________
________________________
______________________
Signature of Applicant
Print Name
Social Security Number
Date
BPR-0009-450
Rules 61K1-3.001 and 61K1-3.007
2015 September
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