APPLICATION FOR ORIGINAL LICENSE —OFFICIAL/JUDGE
Please complete the following form.  Incomplete forms will not be considered.


*Please note that Officials should be more knowledgeable about the sport than the actual participants.  We are looking for qualified individuals who have legitimate and substantial training in combat sports.  You would not want to officiate Basketball if you never participated in a game.

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I am interested in being a, *
Required
 PART 1—APPLICANT INFORMATION
Last Name *
First Name *
Previous Name(s) if applicable:
Social Security Number *
Date of Birth *
(mm/dd/yyyy)
Gender *
Place of Birth *
(city and state, or foreign country)
Mailing Address *
Daytime Telephone Number *
(ex: 555-555-5555)
E-mail Address *
PART 2—LICENSING INFORMATION
Conflict of Interest *
Are you an active Manager, Matchmaker, Fighter, or Trainer of an active Fighter?                                
Experience and Qualifications *
List your experience and qualifications for the license you are applying for:
Licenses/Certificates *
List any licenses or certificates you have that support your qualifications for the license you are applying for: (please note that a Karate Black Belt is not a License or Certificate that applies)
List each jurisdiction in which you are or have been licensed as a MMA or other type of combat sport official or judge *
If not applicable, enter N/A.
PART 3—SCREENING QUESTIONS
Have you ever been suspended, revoked, disciplined or fined by any athletic commission or other organization? *
Have you been convicted of a felony or a misdemeanor? *
If yes, answer the following.  If no, type n/a *
If you answered "Yes" for either of the last two questions you must provide the following:  ○ Date(s) of event/offense ○ Description of event/offense ○ Location/court ○ Case number.   You may be required to provide the following at a later time:   ● Copies of legal documents relating to the event/offense. ● Copies of legal documents indicating your compliance with any requirements imposed upon you.
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*Social Security Number is Required: Effective January 1, 2009, a Social Security Number is required for all licensees. The Commission will consider an application to be incomplete when the applicant fails to submit his/her Social Security Number. Exceptions are made for foreign nationals not currently residing in the United States and for non-immigrants in the United States on student visas. These applicants must submit a signed Social Security Number Affidavit in lieu of a Social Security Number. You may call the Commission to request that an affidavit be mailed to you.

**Disclosure of Addresses: Consistent with Wyoming law, all addresses and phone numbers on record with the Commission are of public record.  It is your responsibility to keep your address, phone numbers and contact information up-to-date in our database. All letters, renewal notices, and licenses are mailed to the last known address of record. If your address is not current, it is possible you will not receive important documents.

***License Expiration: Your license to referee is valid into perpetuity subject to the Commission’s discretion and authority to revoke your license with or without cause. Conditions for reinstatement of license are set forth in the Commission's Rules and Regulations, Chapter 11, Section 11.3.

I state under penalty of perjury in the second degree, that the information contained in this application is true and correct to the best of my knowledge.
False statements made herein are punishable by law and may constitute violation of the practice act.

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