CSC - Promotion Permit Application PART 1
Under s.53 of the Combat Sports Act it is an offence to provide false or misleading information. Maximum penalty $12,000
Generic to All Applicants
Promoters who wish to hold a combat sports contest in Western Australia must hold a permit issued by the Combat Sports Commission. Part 1 Application must be suubmitted not less than 42 days prior to the event.
Applicant Details:
Applicant must have obtained the age of 18 years to be eligible to apply
Full Name
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First Name
Middle Name
Last Name
Address
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Street Address
Street Address Line 2
Suburb
State
Postcode
Please Select
Australia
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Namibia
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Niue
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Saint Barthelemy
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Thailand
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Zimbabwe
Other
Country
E-mail
*
Current Registration Number
if known
Mobile Phone
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Area
Phone Number
Work Phone
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Area
Phone Number
Promotion Details:
Promotion Name
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Promotion Date
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Venue and Address
*
Armadale Arena, Townley St, Armadale
Brown Park Rec Centre, Salisbury Road, Swan View
Champions Gym, 324 Lord Street, Highgate
Craigie Leisure Centre, Whitfords Avenue, Craigie
Eastlake Church, 99 Lakes Road, Greenfields
Halls Head Rec Centre, 42 Honeysuckle Ramble, Halls Head
Herb Graham Centre, Ashbury Crs, Mirrabooka
John Forrest Secondary College, 180 Drake Street, Morley
Kingsway Sporting Complex, Madeley
Metro City, 146 Roe Street, Northbridge
Ray Owen Sports Centre, Gladys Road, Lesmurdie
WA Italian Club, 217-225 Fitzgerald Street, Perth
Other – specify below
If Other, please specify:
Time Doors Open to Public
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Contest Start Time
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Licensed Matchmaker s Name
*
Matchmaker s phone number
*
Weigh In Details:
Weigh in Venue and Address
Bailey Fitness Morley, 222 Walter Road, Morley
Bailey Fitness Southern River, 714 Ranford Road, Southern River
Brown Park Rec Centre, Salisbury Road, Swan View
Champions Gym, 324 Lord Street, Highgate
Combat Sports Commission, 246 Vincent Street, Leederville
Fraser Motorcycles, 47 Walter Road West, Dianella
HBF Arena, Joondalup
Hyde Park Hotel, 331 Bulwer St, Perth
Kalamunda Kickboxing, 1/27 Laurence Road, Walliston
Metro City, 146 Roe Street, Northbridge
Riddler’s Gym, 19 Main Street, Osborne Park
Serpentine Jarrahdale Community Rec Centre
The Game Sports Bar, 90 Aberdeen Street, Northbridge
Total Martial Arts Centre, U7, 17 Townsend Street, Malaga
True Grit, U1b / 7 Rouse Road, Greenfields
Varsity Bar, 33 Rudloc St, Morley
WA Italian Club, 225 Fitzgerald Street, Perth
Other – specify below
If Other, please specify:
Date
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Weigh in Time
*
Strictly 2 hour limit
Entertainment:
Please specify any form of entertainment you intend to have at the promotion
Select all that apply
*
Musical Entertainment
Auctions
Dancing
Other - please specify below
Details of Other
Insurance and Security:
What type of insurance do you intend to provide for contestants and officials?
Policy Type
*
Insurance Provider
*
Cover Amount
AUD $
Medical Practitioner to be utilised:
Medical Practitioner s Name
*
Contact Number
*
Contest Area:
Owner s Name
Owner of contest area to be used
Contact Number
Last Structural Certification by Engineer
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Finance Details:
Matchmaking
*
Cost AUD$
Purses
*
Cost AUD$
Advertising
*
Cost AUD$
Venue Hire
*
Cost AUD$
Medical Practitioner
*
Cost AUD$
Referee
*
Cost AUD$
Judges
*
Cost AUD$
Timekeepers
*
Cost AUD$
Tax (overseas contestants)
Cost AUD$
Airfares/Accommodation
Cost AUD$
Security
*
Cost AUD$
Other
Cost AUD$
Dual Roles at a Promotion:
I will be acting in the following capacities at this promotion:
Where a Promoter is acting in both capacities, a point of contact is required.
*
Promoter Only
Promoter and Trainer
Head Referee:
All Officials (except the Head Referee) must be listed on Part 2 Promotion Permit application.
Head Referee
*
Alan Pond
Bill Seth
Brian Kingwell
Darius Doutch
Gary Ingraham
Justin Boylan
Mark Simpson
Peter Hunt
Other proposed Officials
Date Offiicals were contacted
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Proposed Contestants:
Contestant Name
DECLARATION
I declare that The requirements under the Combat Sports Act 1985 (the Act) as they apply to the contest referred to in the application will be complied with. The information provided in this application is true and correct in every detail. I acknowledge under Section 53 of the Act, I must not include any false or misleading information and if I do, I am liable for a fine of up to $12,000. I understand that it is a requirement for me to provide sufficient financial and material resources to carry out this contest. This includes provision of the resources necessary to comply with the requirements imposed under the Act as they relate to this contest.
Permission to Disclose and Publish Personal Information
I give permission to the WA Combat Sports Commission to publish my personal registration details, contest records and medical details in the database of the Commission and I approve of the Commission disclosing such details to other regulatory bodies in Australia and elsewhere.
By selecting Yes I acknowledge that I have read and understood my requirement to provide sufficient financial and material resources to comply with the requirements imposed under the Act.
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YES
Date
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FEES:
The Promotion Permit fee is based on the number of tickets that are proposed to be made available.
Click to edit
No more than 300 tickets - $100
More than 300 but not more than 700 tickets - $300
More than 700 but not more than 2500 tickets - $600
More than 2500 but not more than 4500 tickets - $1000
More than 4500 tickets - $2500
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