USMTA TITLE QUALIFICATION FORM

To Qualify For a USMTA Title (Pro or Amateur) Print out this form Fill out in Full and Fax to the USMTA at (347-427-0191

PLEASE PRINT NEATLY

Full Name:____________________________________________________________________

Fight Weight: __________ - Height: ____'____ Country:_____________________________

3. Current Age: ________ and date of birth (month, day & year): _______/_______/_______

City: ____________________________ State: _____________ Zip Code: _________________

5. Trainers Name: (SELF if you train yourself)__________________________________________

6. Contact Phone Number: _________________________________________________________

E-Mail (If One): ________________________________@_______________________________

 

AMATEUR FIGHT RECORD WITH KOS IF ANY:

MUAY THAI/ KICKBOXING : ________Wins ________Loses ________Draws ________ WINS BY KO's/TKO'S

 

PROFESSION FIGHT RECORD IF A PRO.

MUAY THAI /KICKBOXING: ________Wins ________Loses ________Draws ________ WINS BY KO's/TKO'S

 

 

I certify the above Is true and confirm so by my signature here:____________________________, Date: ___/___/___

 


WHEN GIVEN A CHOICE PLEASE CIRCLE CORRECT INFORMATION ABOUT THE BOUT DETAILED FOR RULE STYLE WRITE:

FULL CONTACT: FCR - INTERNATIONAL: IR - MUAY THAI: MTR - SAN SHOU: SSR SANDA SDR

 

LAST

BOUTS

PRO

AMATEUR

BOUT RULE

STYLE

BOUT DATE

BOUT OPPONENT

BOUT LOCATION

EVENT PROMOTER

BOUT

RESULT

BOUT

WEIGHT

1

PRO/AM

__________/___/__

W-- L --D

 

2

PRO/AM

__________/___/__

W-- L --D

 

3

PRO/AM

__________/___/__

W-- L --D

 

4

PRO/AM

__________/___/__

W-- L --D

 

5

PRO/AM

__________/___/__

W-- L --D

 

6

PRO/AM

__________/___/__

W-- L --D

 

7

PRO/AMA

__________/___/__

W-- L --D

 

8

PRO/AMA

__________/___/__

W-- L --D

 

9

PRO/AMA

__________/___/__

W-- L --D

 

10

PRO/AMA

__________/___/__

W-- L --D