Form A511-4124NID "Mixed Martial Arts National Identification Card Application Form - Boxing, Martial Arts, and Professional Wrestling Program" - Virginia

What Is Form A511-4124NID?

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 December 7, 2016;
  • 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 A511-4124NID 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 A511-4124NID "Mixed Martial Arts National Identification Card Application 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
MIXED MARTIAL ARTS NATIONAL IDENTIFICATION CARD
Fee $40.00
A check or money order payable to the TREASURER OF VIRGINIA,
or a completed
credit card insert
must be mailed with your application package.
APPLICATION FEES ARE NOT REFUNDABLE.
Select the one method you are requesting:
Identification Card Type:
Trans
X
Initial/First -
1020
MMA National ID Card
Renewal prior to Expiration
2020
Re-Issue of Expired -
1020
MMA National ID Card
No professional Martial Artist is permitted to participate in a Martial Arts event without first presenting a valid Mixed
Martial Arts National Identification Card.
Martial Artists must apply for a Mixed Martial Arts National Identification Card in the state in which he/she is resident or,
in the case of a Martial Artist who is a resident of a foreign country, the Commission of any state that has such a
commission.
Please include the following:
If not a foreign resident, clear photocopy of two (2) of the following government issued IDs, one of which must
contain a photograph:
State driver's license
Social Security card
State identification card
Birth Certificate
If a foreign resident, clear photocopy of foreign passport
Two (2) passport photos
Copy of previous Mixed Martial Arts National Identification Card (For renewal only)
Association of Boxing Commissions' National Identification Card Application (page 2 of this application)
$40 processing fee
"Health and Safety Disclosure"
As per the Muhammad Ali Boxing Reform Act (federal law), each commission must present to every professional boxer, a
medical disclosure upon issuance of a Federal Identification Card.
As a professional boxer you should be aware that this sport includes many health and safety risks, particularly the risk of brain
injury. Therefore, it is strongly recommended that a professional boxer undergo the necessary medical exams that detect
brain injury. If you need further information about these exams, please contact the Commonwealth of Virginia; Boxing, Martial
Arts, and Professional Wrestling Advisory Board or your local boxing commission.
I affirm that I understand the above statement.
Print Name
Signature of Boxer
Date
Passport ID No.
Country
Expiration Date
OFFICE
USE
ONLY
DATE
FEE
TRANS CODE
ENTITY #
FILE #/LICENSE #
ISSUE DATE
OFFICE
4124
USE
ONLY
A511-4124NID-v1
Boxing, Martial Arts, and Professional Wrestling Program/ MMA NATIONAL IDENTIFICATION CARD
12/07/2016
Page 1 of 2
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
MIXED MARTIAL ARTS NATIONAL IDENTIFICATION CARD
Fee $40.00
A check or money order payable to the TREASURER OF VIRGINIA,
or a completed
credit card insert
must be mailed with your application package.
APPLICATION FEES ARE NOT REFUNDABLE.
Select the one method you are requesting:
Identification Card Type:
Trans
X
Initial/First -
1020
MMA National ID Card
Renewal prior to Expiration
2020
Re-Issue of Expired -
1020
MMA National ID Card
No professional Martial Artist is permitted to participate in a Martial Arts event without first presenting a valid Mixed
Martial Arts National Identification Card.
Martial Artists must apply for a Mixed Martial Arts National Identification Card in the state in which he/she is resident or,
in the case of a Martial Artist who is a resident of a foreign country, the Commission of any state that has such a
commission.
Please include the following:
If not a foreign resident, clear photocopy of two (2) of the following government issued IDs, one of which must
contain a photograph:
State driver's license
Social Security card
State identification card
Birth Certificate
If a foreign resident, clear photocopy of foreign passport
Two (2) passport photos
Copy of previous Mixed Martial Arts National Identification Card (For renewal only)
Association of Boxing Commissions' National Identification Card Application (page 2 of this application)
$40 processing fee
"Health and Safety Disclosure"
As per the Muhammad Ali Boxing Reform Act (federal law), each commission must present to every professional boxer, a
medical disclosure upon issuance of a Federal Identification Card.
As a professional boxer you should be aware that this sport includes many health and safety risks, particularly the risk of brain
injury. Therefore, it is strongly recommended that a professional boxer undergo the necessary medical exams that detect
brain injury. If you need further information about these exams, please contact the Commonwealth of Virginia; Boxing, Martial
Arts, and Professional Wrestling Advisory Board or your local boxing commission.
I affirm that I understand the above statement.
Print Name
Signature of Boxer
Date
Passport ID No.
Country
Expiration Date
OFFICE
USE
ONLY
DATE
FEE
TRANS CODE
ENTITY #
FILE #/LICENSE #
ISSUE DATE
OFFICE
4124
USE
ONLY
A511-4124NID-v1
Boxing, Martial Arts, and Professional Wrestling Program/ MMA NATIONAL IDENTIFICATION CARD
12/07/2016
Page 1 of 2
ASSOCIATION OF BOXING COMMISSIONS
ID#
MIXED MARTIAL ARTS
DATE ISSUED
COLOR PHOTO
NATIONAL IDENTIFICATION CARD
(passport type)
ISSUING COMMISSION
APPLICATION FORM
EXP DATE
FIRST NAME
LAST NAME
MIDDLE
ADDRESS
CITY
STATE/PROVINCE
ZIP
-
-
DATE OF BIRTH
SOCIAL SECURITY
HEIGHT:
WEIGHT:
COLOR OF HAIR:
EYE COLOR:
HOME PHONE
EMAIL ADDRESS
ALSO KNOWN AS:
(FIRST NAME)
(LAST NAME)
BIRTHMARKS, SCARES OR TATTOO'S:
TERMS AND CONDITIONS:
1.
Birth name must be used in top name field. If there is a different first or last name place either or both in Also known as
line.
2.
National MMA ID Card will not be issued unless an accurate and truthful application form is completed in its entirety.
Incomplete forms will not be accepted and will be returned to applicant for completion.
3.
Two color (passport type) photos must be submitted with the completed application form.
4.
Two forms of identification must be presented at the time of application and must include a color photo of the applicant.
Accepted forms of identification will include, but not be limited to driver's license, passport, state/province issued
identification or any other form of identification accepted by issuing Commission.
5.
Applicant understands that he/she will not be allowed to compete without a National MMA ID Card.
6.
Applicant understands that the ABC in cooperation with the issuing Commission will settle any and all disputes with
regards to violations of these terms and conditions for the National MMA ID Card. The ruling of the ABC is final and
binding on all parties.
7.
Applicant agrees to abide by these and any other terms and conditions, rules and regulations set forth by the ABC and
the issuing Commission.
8.
Applicant understands and agrees that the ABC reserves the right to amend the terms and conditions for issuing the
National MMA ID Card.
I certify that I have read and understand the terms and conditions pertaining to the application for a National MMA ID Card,
that all information given is my own, is true and correct to the best of my knowledge. I further understand and agree that any
false, misstatements or incomplete information on the application will constitute grounds for revoking or denial of the National
MMA ID Card, and subject me to a one year suspension at the discretion of the ABC or issuing Commission.
Applicant's Signature
Date
Commission Signature
Date
revised: 06/05/2009
Page of 2