Snr.[     ] Jnr. [     ] Age___ Height___ Weight:(     lbs -      lbs) - (      Kgs -       Kgs)

Name:________________________________________________________________________

 Gym/Camp:___________________________________________________________________

Address:______________________________________________________________________   

Street:___________________________________  City:________________________________ 

State:_______________________________  P.Code__________________________________

Home Telephone: (      )_________________  Telephone: (       )________________________

Contact: ______________________________  Fax: (        )____________________________

Trainer/Coach:____________________   Member of:__________________________________

The information I have stated above is to my knowledge true, and and I give permission to the USMTA to forward my Records and Ratings information to registered promoters of the USMTA and affiliated organizations.

Signature:___________________________         Date:________________________________                                  

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 TITLES (if any)

Professional Record (Muay Thai only)   

  WIN: _______ DRAW:________ LOSS:______

National:__________________________   Regional:_________________________

State:____________________________   Inter-Continental:___________________

International:______________________   World:____________________________

Office use only:       

      USMTA MEMBERSHIP No._______________________________

The United States Muay Thai Association is the official U.S. representative of the World Muay Thai Council and the Amateur Muay Thai Association of Thailand, members of the Sports Organization of Thailand, World Amateur Muay Thai Organization. All bouts fought on European soil will be under the Rules and Regulations of the EMTU. International bouts will be recognized if the competing countries  are registered members of the WMTC. All USMTA members must abide by the rules and regulations of the USMTA and will uphold the rituals of respect in the true spirit of the art. By completing this form I have agreed to come under the protection of the USMTA and will pay the annual fees as so stated on my Official Muay Thai Fighters License Agreement of which I have signed.

Copyright Protected 1999 USMTA. Inc.  All rights reserved.

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