Combative Sports Second License Application Instructions (Page 3 of 3) in pdf

PO Box 12157  Austin, Texas 78711-2157

(800) 803-9202  (512) 463-5101  FAX (512) 463-1087

 Combative.Sports@tdlr.texas.gov

COMBATIVE SPORTS SECOND LICENSE APPLICATION

YOU MUST MEET ALL REQUIREMENTS WITHIN 12 MONTHS OF THE FILING DATE, OR THE APPLICATION WILL BE TERMINATED.

APPLICATION FEE: $20 (FEE IS NON-REFUNDABLE)

1. Name:

_______________________________________

_________________________

___________

Last

First

Middle Name

Suffix (JR, SR, III)

2. Date of Birth:

3. Gender:

____________ - _________ - ____________

Male

Female

Month

Day

Year

4. Social Security Number:

______ ______ ______

_____ _____

______ ______ ______ ______

See instruction sheet for disclosure information)

(

5. Foreign National Passport Number: (Foreign nationals must provide their passport number)

_______________________________________________________________________________________

6. Mailing Address:

(A PO box is allowed for this address)

Number, Street Name, Suite Number/Apartment Number

City

State

Zip Code

7. Phone Number:

8. Email Address:

(_______________) ____________________________________________________

_________________________________________________________________________________________

Area Code

Phone Number

(Ex: ) See instruction sheet for disclosure information

9. Have you ever been convicted of, or placed on deferred adjudication for, any

Yes

misdemeanor or felony, other than a minor traffic violation?

If YES, complete and attach a Criminal History Questionnaire for each offense.

See instruction sheet for more information

10. Have you ever had an occupational license, certification

or registration suspended, revoked, or denied in any state?

Yes

If YES, attach a Disciplinary Action Questionnaire to this application. (This does not include your driver license.)

11. Do you have a direct or indirect financial interest in the management of a contestant, manager, or

sanctioning body?

If YES, attach a full explanation.

Yes

12.

STATEMENT OF APPLICANT

I certify that all information is true and correct. I understand that providing false information on this application may result in sanctions up to and includ-

ing denial or revocation of the license I am requesting, and in the imposition of the administrative penalties. I will comply with all applicable provisions

of Chapter 51 and Chapter 2052, Texas Occupations Code, and Texas Administrative Code Title 16, Chapters 60 and 61. I understand that this li-

cense is not transferable. If the license is issued, I agree to furnish to the Texas Department of Licensing and Regulation any change in information

provided on this form within thirty days of the change.

___________________________

________________________________________________________

Date Signed

Applicant Signature

TDLR Form BOX016 rev September 2015