Form Pa-611-020 - Application For Licensure As Manager
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1
2
3BUSINESS AND PROFESSIONS DIVISION
PROFESSIONAL ATHLETICS
P.O. BOX 9649
OLYMPIA, WA 98507-9649
PHONE: (360) 753-3713
FAX: (360) 753-3747
FOR VALIDATION ONLY
001-070-210-0003
APPLICATION FOR LICENSURE
AS
MANAGER
FEE: $40.00
Make remittance payable to:
STATE TREASURER
APPLICATION RECORD
INSTRUCTIONS: All applications must be printed or typewritten. Fee accompanying
Office Receipt
application must be paid by check or money order. Please do not send currency. Two
No.
photos must accompany applications, regular passport size, full face, without hat.
Date received
Click Here to Start, Then Tab From Field to Field
M.O.
Check
Name
Photos
Date approved
Phone (
)
License No.
Date License sent
Street
City
State
Zip
Age
Birth Date
Citizen of
Occupation
Business Address
Business Phone (
)
Social Security No.
ALL APPLICANTS MUST FURNISH THREE REFERENCES
NAME
ADDRESS
PHONE
OCCUPATION
(
)
(
)
(
)
APPLICANT'S STATE EXPERIENCE AND QUALIFICATIONS (Use separate sheet if necessary)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
!
!
Has any boxer under your management or training ever been disqualified for any cause?
Yes
No
If "yes", when and where? Give full particulars:
Were you ever a professional boxer?
Ring Name
Have you any financial interest in any club, corporation, association or organization conducting boxing events in this state or
any other place?
!
!
Have you ever been suspended, penalized or disciplined by any state or boxing/athletic authority?
Yes
No
If "Yes", when and where? Give full particulars:
!
!
Have you ever been convicted of a felony or misdemeanor?
Yes
No
If "Yes", when and where? Give full particulars:
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360) 753-3713 or TTY (360) 586-2788.
PA-611-020 MGR. LIC. APP. (R/11/99)FM/W Page 1 of 3
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