WKA Cornerman License Canadian

WKA Canadian Cornerman's License Application

Complete the form below - after you click Submit you will be sent to the PayPal website to pay for your annual Cornerman's license (expires December 31st of the year). Once payment has been received you will receive your license via email.


First Name	*
Last Name	*
Address	*
City	*
State or Canadian Province	*
Zipcode or Canadian Postal Code	*
Country	*
Phone	*
Email	*
Have you previously been a licensed cornerman for the WKA?	*	No Yes
If so, provide last year licenced

Gym Info
Gym Name	*
Trainer	*
Gym Address
City	*
State or Canadian Province	*
Zipcode or Canadian Postal Code
Country	*
Gym Phone
Gym Fax
Gym Email
Gym Website
How long have you been with this gym?	*
In which sports are you interested in being a second?	*	Muay Thai Kickboxing MMA
Do you have any previous experience as a corner/second?	*	No Yes
If so, for what length of time have you been active as a corner/second?
Describe experience, if applicable
I certify that the competitors listed below are trained and competent in skill to take part in a combative sports competition.
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Signature	*