Arkansas State Athletic Commission

Arkansas State Athletic Commission

Arkansas Department of Health/Combative Sports
4815 W. Markham St. Slot 36 Little Rock, AR 72205 PHONE(501)687-1038 FAX(501)255-0394
Email Address: Internet Address:

Arkansas State Athletic Commission Forms SystemStandard Form – WIR0507-2014

State of Arkansas © 2014 ALL RIGHTS RESERVEDPage 1 of 6

Weigh-In & Inspection Report

Promoter’s Name: / Promoter’s Telephone & Fax #
Event Venue NameLocation:
Event Permit # / Weigh-in Venue Name & Location:
Event Date & Time: / Weigh-in Start/End Time:

License Fees Collected or Due From Promoter

Calculation of Fee(s):
______Announcer License(s) @ $20 Equals$______
______Contestant License(s) @ $20 Equals$______
______Contestant Fed/Nat ID @ $20 Equals$______
______Corner/2nd License(s) @ $15 Equals$______
______Event Coordinator @ $100 Equals$______
______Judge License(s) @ $15 Equals$______
______Manager License(s) @ $50 Equals$______
______Matchmaker License(s) @ $100 Equals$______
______Referee License(s) @ $25 Equals$______
______Timekeeper License(s) @ $15 Equals$______
TOTAL DUE:$______ / Due from Promoter: (Promoter Must Initial By Total Due)
Licensee(s) Whose Fee(s) Are Being Paid by Promoter:
NAMEAMOUNT DUE
TOTAL DUE:$______
Commission/Inspector Weigh-InNotes: / Received Directly from Licensee(s) at Weigh-in or Event:
NAMEAMOUNT DUE
TOTAL COLLECTED:$______

Weigh-In & Inspection Results

MAIN EVENT

BLUE CORNERRED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

UNDERCARD

BLUE CORNERBOUT #1RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #2RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #3RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #4RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #5RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #6RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #7RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #8RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #9RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #10RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #11RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #12RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #13RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #14RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #15RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #16RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

BLUE CORNERBOUT #17RED CORNER

Contestant Name: / VS. / Contestant Name:
Weight:
Inspector’s Initials: / ( )
Rounds / Weight:
Inspector’s Initials:
Pre-Bout B.A.C. Test:
Pass Fail – Result:Inspector’s Initials: / Weight / Pre-Bout BAC Test:
Pass Fail – Result:Inspector’s Initials:
Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used: / Style / Hand Wraps:Inspector’s Initials:
Approved Symbol/Marking Used:
Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used: / Amateur/Pro / Gloves (Size, Condition & Tape):Inspector’s Initials:
Approved Symbol/Marking Used:

COMMENTS/NOTES/EVENT IRREGULARITIES & INFRACTIONS

By my signature below, I certify I personally performed the inspections for which I have initialed and the information herein is true and accurate.

Inspector’s Signature: ______Printed Name: ______Initials: ______Date: ______

Inspector’s Signature: ______Printed Name: ______Initials: ______Date: ______

Inspector’s Signature: ______Printed Name: ______Initials: ______Date: ______

Arkansas State Athletic Commission Forms SystemStandard Form – WIR0507-2014

State of Arkansas © 2014 ALL RIGHTS RESERVEDPage 1 of 6