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MMA, Boxing or Kickboxing Event Detail Form
Your request will be processed in the order it was received, all items must be received at least 7 business days before the event is held.
Please contact the Iowa Division of Labor if you have questions or concerns.
Basic Information
Promoter Name
Promoter Name
Promoter Contact Name
Promoter Contact Name
Title
Title
(optional)
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
(optional)
First
Middle
(optional)
Last
Suffix
(optional)
Degree
(optional)
Promoter Contact Information
Promoter Phone Number
Promoter Email Address
Venue Information
Venue Name
Event Address
Address
(optional)
Address 2
(optional)
City/Town
(optional)
State/Province
(optional)
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
(optional)
Event Date and Time
Event Date and Time: Date
Event Date and Time: Time
Weigh-In Details
Weigh-In Venue Name
Weigh-In Location
Address
Address 2
(optional)
City/Town
State/Province
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
ZIP/Postal Code
Weigh-In Date and Time
Weigh-In Date and Time: Date
Weigh-In Date and Time: Time
Medical Information
Physician Information
Physician Name
Title
Title
(optional)
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
(optional)
First
(optional)
Middle
(optional)
Last
(optional)
Physician Phone Number
Licensing Information
Licensing Information
Has the Physician previously submitted Licensing Information to the Iowa Division of Labor?
Licensing Information
- Select -
Yes
No
Other…
Enter other…
(optional)
Physician License
(optional)
One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
Medical Service Provider
Medical Service Provider (Ambulance Service)
Please provide the name of the medical service provider.
Medical Service Provider Contract Information
Medical Service Contract
(optional)
Choose file
One file only.
50 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
EMT Name(s)
EMT Name(s)
EMT Name(s)
EMT Name(s)
Title
Title
(optional)
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
(optional)
First
(optional)
Middle
(optional)
Last
(optional)
Suffix
(optional)
Degree
(optional)
Item weight
(optional)
Add more items
(optional)
more items
Provide the name of the assigned EMT(s) for this event.
Security Information
Security Firm Name
Security Firm
Security Firm Contact
Security Firm Primary Contact
Title
Title
(optional)
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
(optional)
First
(optional)
Middle
(optional)
Last
(optional)
Suffix
(optional)
Degree
(optional)
Security Firm Contact Info
Security Firm Phone Number
Security Firm Contract
Security Firm Contract File
(optional)
Choose file
One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
Cleaning Services
Cleaning Service Contact
Name of Cleaning Service
(optional)
Cleaning Service Representative
The person responsible for cleaning between rounds.
Cleaning Service Representative
First
(optional)
Middle
(optional)
Last
(optional)
Cleaning Service Rep Phone Number
Cleaning Service Rep Phone Number
Insurance and Bond Information
Insurance Information
Insurance Policy Number
Insurance Policy
A copy of the insurance policy and claim form should be provided.
One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf.
Bond Information
Evidence of a $5000.00 bond must be provided.
Bond
One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf.
Other Information
Other Information
(optional)
Other Attachments
(optional)
Please attach any other information and/or documentation you find necessary with your application.
One file only.
256 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf.
Leave this field blank
(optional)