Promoters application - Office for Recreation and Sport

BOXING AND MARTIAL ARTS ACT 2000SOUTH AUSTRALIAAPPLICATION FOR PROMOTER’S LICENCEI apply to be registered/re-registered as a boxing and/or martial arts promoter.SECTION 1DETAILS OF INDIVIDUAL APPLICANTTitle Mr Mrs Ms Miss DrSurname: _________________________________________________________________Full Given Names: __________________________________________________________Date of Birth: ______________________________________________________________Residential Address: ________________________________________________________Telephone Home: ______________________ Telephone Work: ___________________Mobile: ______________________________Facsimile: ____________________________ Email: ____________________________Postal address: _____________________________________________________________(if the same residential address write “as above”)SECTION 2ENTITLEMENT TO BE REGISTEREDPlease answer Yes or No to the following questions in the space provided below, or on aseparate sheet of paper if the space provided is insufficient.Q1. Have you ever held or do you hold a promoter’s licence (or an equivalent licence) inanother State, Territory or Country? If yes, please provide a copy of your licence.Yes No______________________________________________________________________

- 2 -Q2. Have you ever been convicted of an offence (other than a traffic offence) or are anycourt proceedings pending?(Note - you are required to provide a National Police Clearance Certificate with yourapplication). If yes, please provide details. Yes No______________________________________________________________________Q3. Have you ever been suspended or disqualified from practising or carrying on anoccupation, trade or business in this State or elsewhere? If yes, please provide details.Yes No______________________________________________________________________Q4. Are you an undischarged bankrupt or subject to a Composition, Deed, Scheme ofArrangement with or for the benefit of creditors? If yes, please provide details.Yes No______________________________________________________________________Q5. Have you during the last 5 years, been a director of a Body Corporate that has beenwound up for the benefit of creditors? If yes, please provide details. Yes No______________________________________________________________________SECTION 3APPLICATION DECLARATIONI, the applicant described in this form, do solemnly and sincerely declare that:• I have read the Boxing and Martial Arts Act 2000 and Regulations and understand mylegal obligations if the Promoters Licence is granted; and• the contents of this Application Form and attachments are true and correct and that Iunderstand that providing false or misleading information is an offence under Section18 of the Boxing and Martial Arts Act 2000.I also authorise the Minister for Recreation, Sport and Racing to make any inquiriesnecessary for the purpose of determining this application.I acknowledge that information contained in this form may be made available to interstaterecognised authorities.Signature: _____________________________________________ _______________(of Applicant)(date)

- 3 -SECTION 4ADDITIONAL INFORMATION REQUIRED1. A National Police Clearance Certificate (must be an original document). The certificatemust be no more than three (3) months old preceding the date of lodgement of the licenceapplication. To obtain this certificate you need to apply directly to the South AustraliaPolice.2. Application fees, (cash, cheques or money order) in the sum of $200.00 shall accompanythis application and be made payable to the Office for Recreation and Sport.3. Two recent passport photographs of the Applicant.LODGEMENT OF COMPLETED APPLICATIONPlease return your completed application form with fee to:Boxing and Martial Arts Compliance OfficerOffice for Recreation and Sport27 Valetta RoadKidman Park SA 5025Ph: 8416 6627IMPORTANT INFORMATIONA copy of the Boxing and Martial Arts Act 2000 and Regulations can be obtained fromInformation SA, 77 Grenfell Street, Adelaide, telephone (08) 8204 1900.