WKA USA Amateur Fighter License     First Name * Last Name* Home Address * City * State or Canadian Province*- - Choose One - - AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip Code or Canadian Postal Code* Country - - Choose One - - Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-bissau Guyana Haiti Heard Island And Mcdonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic Of Iraq Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic Of Korea, Republic Of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russian Federation Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Martin Saint Pierre And Miquelon Saint Vincent And The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province Of China Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City St Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe Phone * Phone Type* --Choose One-- Cell Home Work Other Email * Date of Birth (Month-Date-Year Format) * - - 01 02 03 04 05 06 07 08 09 10 11 12 * - - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31* - - 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940Gender* Male Female Weight (lbs.) * Height (Inches)* Do you have health insurance? * No Yes If so, with what company? Gym Name * Trainer * Gym Address City * State or Canadian Province*- - Choose One - - AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NH NJ NL NM NS NT NU NV NY OH OK ON OR PA PE PR QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip Code or Canadian Postal Code Country Gym Phone Gym Website Gym Email How long have you been with this gym? * How long have you studied martial arts?*   Fight Experience Muay Thai (fights with clinch, Thai Boxing, modified Muay Thai, Full Rules Muay Thai) Kickboxing (fights without clinch, low kicks, K-1) Full Contact (fights with no clinch and kicks only above the waist) MMA Boxing Amateur Record Muay Thai Record Win Loss KO Kickboxing Record Win Loss Win KO Full Contact Record Loss KO Loss Mixed Martial Arts Record Win Boxing Record KO Win Loss KO Professional Record Muay Thai Record Win Loss KO Kickboxing Record Win Loss KO Full Contact Record Win Loss KO Mixed Martial Arts Record Win Loss KO Boxing Record Loss Win KO   Last Three Fights Date/Location Type/Division Result i.e. 01-16-97 / Richmond, VA Thai Style / 159-165 lbs. Won - KO 2nd Round 1. 2. 3. Titles List any title(s) and date won Have you fought for the WKA before?* No Yes If so, please list event, date, and location Additional Information I agree to be drug tested and to abide by the U.S. Anti-Doping Agency’s Protocol for Olympic Movement Testing and the AIBA drug testing rules. * Have you ever competed professionally?* No Yes I have read the Waiver of Liability and agree to the terms and conditions. * Once you click "Submit" below you will go to the WKA Fighter License page where you have the option to apply and pay for a WKA Fighter License. If you do not have a valid WKA Fighter License you may fill out the form and submit your payment. Once we have received your payment, you will receive your WKA Fighter license by email. A WKA Fighter License is required to compete in any WKA sanctioned event.