LOUISIANA STATE BOXING & WRESTLING COMMISSION

P. O. Box 13126 Monroe, LA

318-***-****

LICENSE APPLICATION

To the Louisiana Boxing & Wrestling Commission:

The undersigned having paid the legal fee as required by law, hereby makes application for a license as a: (circle only one)

JUDGE $25.00 BOXER $25.00 MATCHMAKER $250.00

TIMEKEEPER $25.00 MANAGER $25.00 BOXING PROMOTERS $500.00 ANNOUNCER $25.00 WRESTLING $25.00

REFEREE $25.00 KICK BOXER $25.00 WRESTLING & MIXED SECOND $25.00 OTHERS $25.00 TECH. EVENT PROMOTER $250.00 For the year ending December 31, 20 and hereby makes the following representations: Last Name First Name D.O.B. S.S. # Street City State Zip Telephone Manager Have you ever been denied a license or ever had a license suspended or revoked by any athletic commission? Yes No . If yes, explain fully: CONTRACT RELEASE

Contract of Release executed by hereinafter referred to as “Releasor”.

In consideration of being permitted to compete and participate in any professional contest or exhibition under the jurisdiction of, or sanctioned by the Louisiana state Boxing & Wrestling Commission, held in the State of Louisiana, Releasor, for himself, and personal representatives, assigns, heirs, and next of kin, hereby releases, waives, and discharges the State of Louisiana and the Louisiana State Boxing and Wrestling Commission, its members, officers, agents, and employees (hereinafter referred to as “Releasees”) from all liability to the Releasor, his personal representatives, assigns, heirs, and next of kin for all loss or damage and any claim of damages thereof, on account of injury to the Releasor or his property or resulting in the death of Releasor, whether caused by the negligence of Releasees or otherwise while the Releasor is competing in any professional contest or exhibition under the jurisdiction of, or sanctioned by, the Louisiana State Boxing and Wrestling Commission.

Releasor agrees to indemnify the Releasees and each of them from any loss, liability, damage or costs Releasees may incur during the contest or exhibition held in the State of Louisiana, whether caused by the negligence of the Releasees or otherwise. Releasor hereby assumes full responsibility for any risk of bodily injury, death or property damage due to the negligence of Releasees or otherwise while participating in any contest or exhibition in the State of Louisiana while competing, officiating in, working, or for any other purpose participating in said contest or exhibition, under the jurisdiction of, or sanctioned by the Louisiana State Boxing and Wrestling Commission. Releasor expressly agrees that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Louisiana and that if any portion hereof is deemed invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. Releasor further releases all officials and professional personnel of the Louisiana State Boxing and Wrestling Commission from any claim whatsoever on account of first aid treatment or service rendered during participation in any contest or exhibition in the State of Louisiana. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. Releasor further states that he/she is of lawful age and is competent to enter such a release, that he/she has carefully read the foregoing release and knows the content thereof and knows that he/she is participating in an inherently dangerous event, and signs this release of his/her own free will. Date: Signed: Witness: Releasor and Licensee

FOR OFFICIAL USE ONLY

Date: Signed: Louisiana State Boxing and Wrestling Commission License No. Date Issued Issued by: