Form A511-4130EXP "Amateur Sanctioning Organization - Experience Verification Form - Boxing, Martial Arts, and Professional Wrestling Program" - Virginia

What Is Form A511-4130EXP?

This is a legal form that was released by the Virginia Department of Professional and Occupational Regulation - a government authority operating within Virginia. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the Virginia Department of Professional and Occupational Regulation;
  • 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 fillable version of Form A511-4130EXP by clicking the link below or browse more documents and templates provided by the Virginia Department of Professional and Occupational Regulation.

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Download Form A511-4130EXP "Amateur Sanctioning Organization - Experience Verification Form - Boxing, Martial Arts, and Professional Wrestling Program" - Virginia

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Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-0186
www.dpor.virginia.gov
Boxing, Martial Arts, and Professional Wrestling Program
AMATEUR SANCTIONING ORGANIZATION - EXPERIENCE VERIFICATION FORM
1.
Sanctioning Organization Name
2.
Sanctioning Organization Contact Numbers
Primary Telephone
Alternate Telephone
3.
Which experience category is being used to qualify the amateur sanctioning organization for approval? (Select only one)
This organization has a minimum of five years of experience as a martial arts sanctioning organization, representing at least two different promotions during such
five-year period in any United States jurisdiction(s).
Complete SECTION
4.
This organization's responsible management/principal officers (separately or individually) have at least eight years of experience working as a referee or head
official for an established sanctioning organization in any United States jurisdiction.
Complete SECTION 5.
Individuals must be listed in question #9 as
responsible management/principal officers on the Amateur Martial Arts - Sanctioning Organization Approval Application.
SECTION 4 Provide examples of the experience obtained: (List at least 1 event per year)
Organization/Individual
Venue Information
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Address
City
State
Professional/Amateur
Fighters
Bouts
1.
Name of Promotion Represented:
Brief Description of Event:
Organization/Individual
Venue Information
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Professional/Amateur
Fighters
Bouts
Address
City
State
2.
Name of Promotion Represented:
Brief Description of Event:
A511-4130EXP-v2
Virginia Boxing, Martial Arts, and Professional Wrestling Program/EXP VER FORM
07/01/2016
Page 1 of 3
Commonwealth of Virginia
Department of Professional and Occupational Regulation
9960 Mayland Drive, Suite 400
Richmond, Virginia 23233-1485
(804) 367-0186
www.dpor.virginia.gov
Boxing, Martial Arts, and Professional Wrestling Program
AMATEUR SANCTIONING ORGANIZATION - EXPERIENCE VERIFICATION FORM
1.
Sanctioning Organization Name
2.
Sanctioning Organization Contact Numbers
Primary Telephone
Alternate Telephone
3.
Which experience category is being used to qualify the amateur sanctioning organization for approval? (Select only one)
This organization has a minimum of five years of experience as a martial arts sanctioning organization, representing at least two different promotions during such
five-year period in any United States jurisdiction(s).
Complete SECTION
4.
This organization's responsible management/principal officers (separately or individually) have at least eight years of experience working as a referee or head
official for an established sanctioning organization in any United States jurisdiction.
Complete SECTION 5.
Individuals must be listed in question #9 as
responsible management/principal officers on the Amateur Martial Arts - Sanctioning Organization Approval Application.
SECTION 4 Provide examples of the experience obtained: (List at least 1 event per year)
Organization/Individual
Venue Information
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Address
City
State
Professional/Amateur
Fighters
Bouts
1.
Name of Promotion Represented:
Brief Description of Event:
Organization/Individual
Venue Information
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Professional/Amateur
Fighters
Bouts
Address
City
State
2.
Name of Promotion Represented:
Brief Description of Event:
A511-4130EXP-v2
Virginia Boxing, Martial Arts, and Professional Wrestling Program/EXP VER FORM
07/01/2016
Page 1 of 3
Organization/Individual
Venue Information
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Address
City
State
Professional/Amateur
Fighters
Bouts
3.
Name of Promotion Represented:
Brief Description of Event:
Organization/Individual
Venue Information
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Professional/Amateur
Fighters
Bouts
Address
City
State
4.
Name of Promotion Represented:
Brief Description of Event:
Venue Information
Organization/Individual
Event Type
No. of
No. of
Exp.
Date of Event
No.
(Experience obtained by)
Professional/Amateur
Fighters
Bouts
Address
City
State
5.
Name of Promotion Represented:
Brief Description of Event:
A511-4130EXP-v2
Virginia Boxing, Martial Arts, and Professional Wrestling Program/EXP VER FORM
07/01/2015
Page 2 of 3
SECTION 5 Provide information for individual referee/head official experience.
Name of Responsible Manager/
Referee or
From
To
Sanctioning Organization
Address
City
State
Phone
Principal Officer Reporting Experience
Head Official?
MM/YYYY
MM/YYYY
Add
Delete
6.
Sanctioning Organization's Responsible Management - Officers, Owners, or Agent's Signatures is required
Print Name
Title
I, the undersigned, certify that the foregoing statements and answers are true, and no information has been suppressed that might affect the Director's decision to grant
approval.
Signature
Date
A511-4130EXP-v2
Virginia Boxing, Martial Arts, and Professional Wrestling Program/EXP VER FORM
07/01/2015
Page 3 of 3
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