Physician License - Nigeria Boxing Federation

Physician License Registration Form

Kindly provide the Boxer License Registration Code sent to you from the NBF-PRO Desk Officer after you filled the NBF-PRO License Acknowledgement Form. You must get the Boxer License Registration Code before you fill this form

any ownership Phone

Full Name

First

Middle

Last

Date of Birth

Gender

Female
Male

Origin

Nationality

Local Government of Origin

Place of Birth

Contact

Phone Number

Alternate Phone

Email

Confirm Email

Residential Address

Country of Residence

Local Government of Residence

Detailed Residential Address

Office / Hospital Address

Country of Hospital

Local Government of Hospital

Detailed Hospital Address

SECTION B: MEDICAL LICENSURE, CREDENTIALS AND IDENTIFICATION

ID Document Type

National ID Card
International Passport
Driver's License
Voter's Card

(Provide at least one valid government-issued ID)

Medical School Attended

Medical School Year of Graduation

Medical License Number

License Issuing Body

License Expiry Date

Current Hospital / Clinic Affiliation

SECTION C: RINGSIDE MEDICAL EXPERIENCE

Years of experience as ringside physician

Number of professional boxing events covered:

Number of olympic style (amateur) boxing events covered:

Total number of boxing events covered:

Boxers Managed

SECTION C: BOXING EXPERIENCE

Years of experience in boxing

Previous experience (check all that apply)

Previous experience (others, please specify)

Please describe your matchmaking experience:

Have you ever worked as a matchmaker before?

Yes
No

Have you ever worked as a matchmaker before? Yes. For which promoters/promotions

SECTION D: RELATIONSHIPS AND CONFLICTS

Do you currently have, or have you had in the last 2 years, any financial interest in any boxer?

Yes
No

Do you currently manage any boxers?

Yes
No

Do you have any ownership interest in any promotion company?

Yes
No

SECTION E: CRIMINAL HISTORY AND DISCIPLINARY RECORD

Have you ever been convicted of a crime?

Yes
No

Have you ever had a boxing license suspended or revoked?

Yes
No

Have you ever been fined by any boxing commission?

Yes
No

SECTION F: ACKNOWLEDGEMENT, DECLARATION AND SIGNATURE

I, (Above Named) acknowledge that I have received and reviewed the NBF-PRO Licensed Personnel Handbook (Version 1.0, 2026). I understand that:
1. This handbook contains important information about my rights and responsibilities as a licensed person.
2. I am responsible for knowing and complying with all rules, regulations, and policies contained in this handbook.
3. The NBF-PRO may update these rules, and it is my responsibility to stay informed of changes.
4. Ignorance of the rules is not a defense for violations.
5. I must maintain current contact information with the NBF-PRO Licensing Department.
6. I must complete required continuing education and renew my license annually.
I agree to abide by all NBF-PRO rules and the Code of Conduct.

Signature

Clear Signature

Date

Passport Photograph

Click or drag a file to this area to upload.

I, (Above Named) declare that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in immediate rejection of this application, revocation of any license issued, and disciplinary action. I have read and understand the NBF-PRO Rules and Regulations and agree to be bound by them. I agree to submit to medical examinations and drug testing as required. I agree to conduct myself in accordance with the NBF-PRO Code of Conduct. I authorize the 'Nigeria Boxing Federation' to verify any information provided in this application, including criminal background checks and verification of records with other boxing commissions.

Yes

SECTION G: FOR OFFICIAL USE ONLY

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