Nova Scotia Combat Sports Authority
       APPLICATION FOR A PARTICIPANTS LICENSE	
741 Bedford Highway
Halifax, NS  B3M 2M1
phone: 902 457–0413
phone: 902-869-3696
fax: 902 484-6937	
Fee: $50.00 For Contestant $25.00 for Manager, Seconds and Matchmaker

TYPE OF LICENSE SOUGHT (please circle one):    Contestant      Manager      Second     Matchmaker	

APPLICANT	
		Last Name			Given Name(s)		Alias (if applicable)
CURRENT     											
ADDRESS		
		Number & Street	Apt. #	     City/Town 	                        Postal Code
MAILING
ADDRESS	○ as above or

CONTACT
NUMBERS	(       )          -                      (       )          -                                               
		Home			Work			Email Address

PERSONAL		|    |    | / |    |    |    | / |    |    |
		DOB:	   Day /   Month     /Year      Birthplace (Town/City/Prov/State/Country)	

GOVERNMENT
ISSUED ID 	|    |    |    |    |    |    |    |    |    |    |    |    |    |    |
		Master Number (Attach a legible copy of the front and back of the identification card)
___________________________________________________________________________________
WAIVER 	I, the undersigned, fully understand and agree that, in the event that I participate in any contest in the Province of Nova Scotia, I shall submit to a post-fight urinalysis test to be conducted by the Nova Scotia Combat Sports Authority Medical Advisor, or a medical doctor approved by the Authority.

	______________________	___________________________________________
	Date				Applicant Signature (Contestant)

AGREEMENT	I, the undersigned, fully understand that to the best of my knowledge and belief, the information contained in the application is true and accurate. I understand that to submit a license application containing false or inaccurate information is a violation of the Nova Scotia Combat Sports Authority Act and may result in revocation of the license, the imposition of a fine or both, at the discretion of the Authority.

		_______________________	___________________________________________
		Date				Applicant Signature

I, the undersigned, fully understand and agree that the Nova Scotia Combat Sports Authority may from time to time disclose my personal information (including, but not limited to medical information and the information contained in this application form) to other combat sports authorities as may reasonably requested by such authorities. Furthermore, I understand and agree that my full name, date of birth and the status of my license may be disclosed to the public, and may be posted on the Nova Scotia Combat Sports Authority website

		__________________________        ________________________________________________
		Date				Applicant Signature

NOVA SCOTIA COMBAT SPORTS AUTHORITY USE ONLY

Fee Paid?		Y	N	Comment: ______________________________________________

Approval Granted?	Y	N	Comment: ______________________________________________

___________________	___________________________   	_________________________________
Date			Secretary-Treasurer - NSCSA	Chairman - NSCSA