Competitor Information
**You must be over 13 years of age before submitting any information.**

(* - Required)

* First Name: * Last Name:
* Street Address:
* City:
* State:
* Zip:
* Country:
* Phone:
* Email:
* Weight:
* Height:
Date of Birth (mm/dd/yyyy):
* Gender:

Do you have a current passport?
If yes, please enter the country for which the passport is valid:


Do you have health insurance?


Do you have a WKA lincense?


Gym:
Trainer:
Gym Address:
City:
State:
Zip:
Country:
Gym Phone:
Gym Email:
Gym Fax:
How long have you been with this gym?:
How long have you studied martial arts?:

Fight Experience


Current Status: Amateur Professional

Amateur Record:
Muay Thai Record:
Kickboxing (Low-Kick) Record:
Full Contact Record:
Mixed Martial Arts Record:

List titles and date won:

Professional Record:
Muay Thai Record:
Kickboxing (Low-Kick) Record:
Full Contact Record:
Mixed Martial Arts Record:

List titles and date won:

List last 3 fights: (Date, Event, Location, Result)


Have you fought for the WKA before? Yes No
If so, please list the event, location, and date:

Additional Information:

**You must be over 13 years of age before submitting any information.**

**Please verify all information is correct. We will be unable to contact you if any of the information is not valid.**

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Last updated September 29, 2003.