Fighter Registration

Fighter Registration

First Name
Last Name
Street Address
City
State
Zip
County
Home Phone
Work Phone
Cell Phone
E-Mail
Place of Employment

Please identify and describe yourself:

Age
Weight
Fight Weight
Height
Date of Birth
Sex	Male Female

Fight Information:

Current Status	Amateur Professional
Ring Name
Fighting Style
Years of Training
Fight Record
Fight School Name
List Last 3 Fights (Date, Event, Location, Result) 1.
2.
3.
Intro Song Title w/Artist

How did you hear about the event?:

Radio
TV
Newspaper
Poster
Internet
Word of Mouth

Which upcoming show were you interested in fighting?:

May Schedule			June Schedule

May 10			June 14
Abingdon, VA			Charlotte, NC


May 24
Raleigh, NC

Attention: Any fighter fighting in a North Carolina event will need the following exams:

1. A full dilated eye examination performed by a licensed ophthalmologist and submitted on a

form provided by the Division within the past 12 months. Print Eye Exam Form

2. HIV within the last 180 days.

3. Hepatitis B surface antigens within the past 180 days.

4. Hepatitis C antibody.

If a contestant fails a Hepatitis B surface Antigen test, the contestant must pass a Hepatitis B "PCR" quantitative test. The quantitative limit must be within permissible limits according to the laboratory where test were administered. The test and results must not be older than 180 days from date of the receipt of report by the Division and must be submitted on letterhead of the laboratory, accompanied by contestant's declaration under penalty of perjury that the report represents the contestant's most recent HIV, Hepatitis B and Hepatitis C test results.

Promoter needs tests in hand 10 day prior to event to submit to NC Boxing Authority.

Tell us why you should be selected to fight on Ruckus in the Cage?:

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