Officiant Application - New Brunswick Combat Sport Commission

Officials License Application

Type of license you are applying for*

Referee
Timekeeper
Judge
Room Supervisor

Name*

First Last

Your Age*

Please enter a number from 12 to 150.

Date of Birth*

Valid Email Address*

Address*

Street Address Address Line 2 City Province Postal Code

Phone Number*

How long have you lived at this address? (in Years)*

Other Address' for past 3 years*

If lived at primary addressis less than 3 years, list address(es) for past 3 years

Current Occupation

Employer

Contact Name in Case of Emergency

Relationship

Phone Number of Contact

Email Address of Contact

Related LIcences

Do you have, or have you held, a valid combat sport (Boxing, MMA, Kick Boxing, etc.) related licence in any other jurisdiction?*

Name of Issuing Authority*

Contact for Issuing Authority

Phone

Email

Type of License

Licence Number

Expiry Date

Statement of Disciplinary Action

Have you ever been disciplined by a combat sport authority?*

Date

Authority

Allegation

Result

Criminal Charges or Conviction

Have you ever been charged or convicted of a criminal offence in any jurisdiction?*

Offence

Date

Result

Sports you wish to officiate

In which combat sports are you seeking a licence?

MMA
Boxing
Kick Boxing
Other (please text)

Other Sports in Which You are Seeking a Licence*

Please list below your experience as an official and contestant in combat sport (Boxing, MMA, Karate, etc.).

Official:

Contestant:

Courses Clinics Etc

List by date, subject study, and location of any courses, clinics etc. you have attended related to officiating

Date (yyyy/mm/dd)	Subject study	Location

Attach Optometrist or Ophthalmologist Report for Judge and Referee Only.*

Max. file size: 256 MB.

Medical Records Agreement*

I hereby authorize the NB Combat Sport Commission or its representative to access any of my previous medical records. Further, I agree to submit to blood tests and urinalysis when requested and any medical examination, neurological/psychometric evaluation required in connection with this licence application and any contest during the currency of

I Agree

Personal Information Declaration*

The personal information that you have provided to us to enable us to respond to your inquiry will only be used for that purpose. You will not be placed on any mailing lists, nor will your information be released to any third party, except as may be authorized by law. The authority for obtaining this information from you complies with Part 3 of Bill 89 of the Right to Information and Protection of Privacy Act. I hereby authorize the NB Combat Sport Commission or its representative to transmit any information contained in this application, or in any document required to be filed herewith, to any authority connected to the regulation of combat sports. Further, I acknowledge that false, inaccurate or incomplete information provided in this application may be cause to refuse to issue, or cancel a licence at any time. I also agree to adhere to the Code of Conduct established by the NB Combat Sport Commission.

I Agree

Licence Application Fees

Licence Fees

Price:

Licence Fees - Timekeeper

Price:

My Billing Address is:

Same as primary address above
Different than primary address above

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country