* - Indicates mandatory field. Click Submit when finished.

Name*                 

Payer's Name*    

Address Line 1*

Address Line 2  

Address Line 3  

Telephone:

Home                  -

Work                  -

Cell*                    -

Email*                 

Nationality*         Trinidad and TobagoBarbadosJamaicaAfghanistanGrenadaAlbania AlgeriaAndorraAngolaAntigua and BarbudaArgentina ArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBelarusBelizeBelgiumBeninBhutanBoliviaBotswanaBosnia and HerzegovinaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape Verde Central African RepublicChadChileChinaCuracoaCayman IslandCancun & Cozumel ColombiaComorosCongoCosta RicaCôte d'IvoireCroatiaCuba CyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGuadeloupeGermanyGeorgiaGhanaGreeceGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJapanJordanKazakhstanKenyaNorth KoreaSouth KoreaKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyaLithuaniaLuxembourgMacaoMacedoniaMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMicronesiaMoldovaMonaco MongoliaMoroccoMexicoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigeriaNorwayOmanPanamaPeruPakistanPapua New GuineaPalauPoland PortugalQatarRomania RussiaRwandaSt. Kitts and NevisSaint LuciaSt. Vincent & the GrenadinesSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomalia South AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaTogoThailand TunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVenezuelaVietnamWest BankWestern SaharaYemenZambia Zimbabwe TahitiAnguillaArubaBonaireMargaritaMonserratNevisTurks and CaicosU.S. Virgin IslandsMartiniqueBritish Virgin IslandsNetherlands AntiliesPuerto Rico

Date of Birth*    

Gender*             Male Female

Fight Weight*     lbs kg

Height*               feet inches

Trainer's Name*

Amateur Fight Record with KOs if any:

Rule Style (tick the appropriate box in which you wish to compete and be ranked)* :

Kickboxing San Shou MMA

Most Recent Bout Information:

Name of Opponent

Type of Event:        Kickboxing Boxing San Shou MMA

Status of Fight:      Amateur Professional

Venue                    

Date                       

Sanctioning Body   

Result of Fight        

Ranking[s] and Title[s] under other organizations (IF ANY):

Have you ever fought as a PROFESSIONAL in ANY Fight or Striking Sport (Kickboxing, Boxing, San Shou or MMA)?*
Yes No

Have you ever been paid (directly or through your trainer/manager) for fighting in a Fight or Striking Sport (Kickboxing, Boxing, San Shou or MMA)?*   Yes No

Contact Information to be listed in rankings :

Tel.*    -

Fax.    -

Email*