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*
First Name Middle Name Last Name

Address*

Street Address
Street Address Line 2
Suburb	State
Postcode	Country

E-mail*
Current Registration Number
if known
Mobile Phone*
( ) Area Phone Number
Work Phone
( ) Area Phone Number
Promotion Details:
Promotion Name*
Promotion Date*
Day Month Year
Venue and Address*
If Other, please specify:
Time Doors Open to Public*
Contest Start Time*
Licensed Matchmaker s Name*
Matchmaker s phone number*
Weigh In Details:
Weigh in Venue and Address
If Other, please specify:
Date*
Day Month Year
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
Day Month Year
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*
Other proposed Officials
Date Offiicals were contacted
Day Month Year
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.*

YES
Date*
Day Month Year
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
Should be Empty:

CSC - Promotion Permit Application PART 1

Generic to All Applicants

Applicant Details:

Promotion Details:

Weigh In Details:

Entertainment:

Insurance and Security:

Medical Practitioner to be utilised:

Contest Area:

Finance Details:

Dual Roles at a Promotion:

Head Referee:

Proposed Contestants:

DECLARATION

Permission to Disclose and Publish Personal Information

FEES: