Fillable Promoter Fighter Meeting Physical Exam Attach copy of (Office of the Chief Information Officer)

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Promoter Fighter Meeting Physical Exam Attach copy of (Office of the Chief Information Officer)

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The Promoter Fighter Meeting Physical Exam Attach copy of (Office of the Chief Information Officer) form is 1 page long and contains:

  • 1 signature
  • 6 check-boxes
  • 58 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Office of the Chief Information Officer

BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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MMA, Boxing or Kickboxing Promoter Event Application
This form must be submitted 7 days or more prior to the event
Promoter
Address
City
State
Zip
Phone number
Fighter Meeting
Location address
City
Physical Exam – Attach copy of medical license
Ringside physician name
Address
City
State
Zip
Phone number
Email address
Place
Address of physical exam
City
Zip
Weigh-in
Name of official
Date
Address
City
Zip
Officials (2 Required)
Name
Phone number
Name
Phone number
Timekeeper (1 Required)
Name
Phone number
Name
Phone number
Judges (3 Required)
Name
Phone number
Name
Phone number
Name
Phone number
Name
Phone number
Emergency Medical Service – Attach copy of contract with ambulance service including name of EMT attending event
Name of ambulance service
Phone number
City
State
Zip
Law Enforcement and Security Firm – Attach copy of contract with security firm
Law enforcement
Phone number
Security firm name
Phone number
Cleaning Between Rounds
Name
Phone number
All fields are required, once completed attach ALL of the 7 items below and send to the Iowa Athletic Commission.
1. $225.00 - One half of application fee 5. $5,000.00 bond payable to the State of Iowa
2. Certificate of Insurance 6. Copy of contract with the security firm
3. Copy of contract with each contestant 7. Copy of medical license of the ringside physician
4. Copy of contract with emergency medical service including name of EMT
I certify that the information on this form and attachments (if any) is true and accurate to the best of my knowledge.
Printed promoter name Signature Date
Iowa Division of Labor
Athletic Commission
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-745-2632
Fax: 515-281-5361
athletics.iowa.gov
athletics@iwd.iowa.gov
900-002
06.16.2020
Event Date:
Promoter Name:
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Promoter Fighter Meeting Physical Exam Attach copy of (Office of the Chief Information Officer)

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Completed 20 July 2020

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