August 9th 2008 James E. Carnes Center St. Clairsville, OH

Please make sure to fill in all fields, if it does not apply please put in N/A or form will not be sent. ----------Personal/Contact Information---------- What city do you want to fight in: Name: Ring Name: Address: City: County:   State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip Code: Previous address if you have lived in this state less than 1 year: Telehone(Daytime): Telephone(Evening): Email Address: Age:  Ht:  Wt:  Birthdate: Social Security Number: Marital Status: Single Married Divorced  Spouse Name:  Number of kids:   Name of Employer: Address of Employer: Job Title: Business Phone: Are you currently or have you ever served in the Military? No Yes What branch: When? Where?   ----------Health Information---------- Do you have any prior illness or physical problems?(list any): Have you had a physical examination within the last 12 months? Yes No Is yes give Doctors name:   Have you ever been hospitalized for any reason? No Yes If Yes then Why?   Hospital: Phone:   Do you have ANY physical problems?   Yes No if yes, Please give date & details.   Have you EVER had a concussion?   Yes No if yes, Please give date & details.     ----------Previous Fight History---------- Have you ever fought in any of the following and how many fights have you had? MMA: No Yes                    Number of fights: Wrestling: No Yes      Years of Experience: Amateur Boxing: No Yes   Number of fights: Pro Boxing: No Yes           Number of fights: Kick Boxing: No Yes         Number of fights: Toughman Contest: No Yes     Number of fights:   Have you ever Won a Toughman Contest or any similar event? No Yes City: Date: Are you currently or have you previously participated in any organized sport? No Yes What sport?  When? Where? Have you ever had any professional fights?   No Yes   How did you hear about this contest? Former Fighter  Newspaper  TV  Radio  Poster  Other   I certify that the information contained in this entry form is true and complete. Full Name: