01/18/12 #2964 Boxing or Mixed Martial Arts Second License

Transcript

1 - Department of Safety and Professional Services 8503 Phone: 608 Wisconsin 261 - Unarmed Combat Sports Email: [email protected] P.O. Box 8935 Web: http://dsps.wi.gov Madison, WI 53708 -8935. , Governor Tony Evers , Secretary Dawn Crim Second License Unarmed Combat Sports Your application will not be processed or will be delayed unless you: must complete all sections including your social secu rity #. Complete [ ] 1. the application information section on the first page . You [ ] 2. Complete the certification of legal status section on this application. . Read and sign the affidavit of applicant. [ ] 3 . Credential fee ($40 per year). - ted below. or fill in the credit/debit card section with the appropriate amount lis check [ ] 4 Attach Note: Applicants that are 16 or 17 years of age may now become licensed as a second . However, if you are under 18, you may not accompanied by a licensed second who is at years of age. 18 assist a contestant at an event unless ormation (Print in ink or type) Applicant Inf 1. Unarmed Combat Sports Second ) (265 Name (First, Middle and Last): Applicant’s Date of Birth: Applicant’s : Applicant’s Social Security # Street Address or PO Box: State City Country, If Other Than United States: Zip Code Fax Number (Including area code): Telephone Number (Including area code) mail Address: E - The department may not disclose the social security number collected above except to the Department of for Children and Families purposes of administering the child and spousal support program and to the Department of Revenue for the purpose of determining whether you are liable for delinquent taxes. For Receipting Use Only Wisconsin Department of Safety and Send application and payment to: Professional Services, Attention Unarmed Combat Sports Program, P.O. Box $40 $80 $120 $160 $200 - 265 8935 Madison, WI 53708- 8935. Department of Wisconsin Overnight mail delivery and Office location: Safety and Professional Services, Attention Unarmed Combat Sports Program, 4822 Madison Yards Way, Madison, WI 53705 All ot her correspondence: Fax: 608- TTY: Contact through Relay, 3036, 261- Phone: 608- 251- 8503, http://dsps.wi.gov or by online: email: [email protected] 2/17) (CH.440, Stats and Ch. 444, Stats) #2964 (Rev.

2 2. Certification of Legal Status: I declare under penalty of law that I am (C heck one):  a citizen or national of the United States, or a qualified alien or nonimmigrant lawfully present in the United States who is eligible to receive this professional license  as defined in the Personal Responsibility and Work Opportunities Reconc ct of 1996, as codified in 8 U.S.C. iliation A §1601 et. Seq. (PRWORA). For questions concerning PRWORA status, please contact the U.S. Citizenship and . 5283 or online at http://www.uscis.gov Immigration Services in the Department of Homeland Security at 1 -800- 375- t this change Should my legal status change during the application process or after a credential is granted, I understand that I must repor to the Wisconsin Department of Safety and Professional Services imm ediately. 3. Affidavit of Applicant CONTINUING DUTY OF DISCLOSURE I understand that I have a continuing duty of disclosure during the application process. If information I have provided in t his stand that I am obliged to provide any necessary information to ensure the application becomes invalid, incorrect or outdated, I under information on my application remains current, valid, and truthful. I understand that Credentialing authorities may view acts of omission as dishonesty and that my duty of disclosu re during the application process exists until licensure is granted or denied. AFFIDAVIT OF APPLICANT I declare that I am the person referred to on this application and that all answers set forth are each and all strictly true in every respect. and that f ailure to provide requested information, making any materially false statement and/or giving any materially false I underst information in connection with my application for a credential or for renewal or reinstatement of a credential may result in credent ial ther applic ation processing delays; denial, revocation, suspension or limitation of my credential; or any combination thereof; or such o eof, failure ement ther penalties as may be provided by law. I further understand that if I am issued a credential, or renewal, or reinstat to comply with the statutes and/or administrative code provisions of the licensing authority will be cause of disciplinary ac tion. By signing below, I am signifying that I have read the above statements (Certification of Legal Sta tus, Conti nuing Duty of Disclosure -holder should information I’ve provided and Affidavit of Applicant) and understand the obligation I have as an applicant or credential to the Department of Safety and Professional Services change. _______________________________________________________________ re Date (m o/day/yr) Applicant’s Signatu 4. Credential Fee (nonrefundable): Cho ose the length of your license ($40 per year): 1 year - 2 years - $80  3 years - $120  4 years - $160  5 years - $200   $40 payable to: State of WI – R Pay by Check - Make checks DSPS O Fill in the information below. Pay by Credit or Debit Card – Please Note: For all credit and debit card transactions, a 2% convenience fee will be assessed and will appear as a separate charge on ble. your statement. This fee is non -refunda Daytime __ __ __ __ (__ _ Phone Number: _ __) __ __ __ - Cardholder’s Name: __________________________________ Cardholder’s Address: ______________________________________________________________________________ ( Street) Code ) (City) (State) (Zip Credit Card Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ Expiration Date: __ __ / __ __ __ __ Type : Visa MC Disc AmEx (Circle One) Security code from front/back of card:__ __ __ __ I understand by si gning below, I authorize the State of Wisconsin Department of Safety and Professional Services to charge my credit card for the above amount and a 2% convenience fee assessed at the time of processing. _____________________________________________________________________ Cardholder’s Signature:

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