DECLARATION, ACKNOWLEDGEMENT AND CONSENT
I declare that:
- the serological clearance certificate and/or the certificate of fitness that I am providing to the Combat Sports Authority of NSW was/were given by a registered medical practitioner or pathology service provider and that I was subject to the medical examinations and tests that resulted in the certificate being given;
- I have not altered, changed, amended, deleted or added any information contained in the certificate(s);
- I have personally made this application and provided all accompanying documents.
I understand that:
- it is an offence to make a false or misleading statement in relation to this application under the Crimes Act 1900 (NSW);
- it is an offence under section 92 of the Combat Sports Act 2013 (NSW) to provide false or misleading information or document in connection with:
- any application under the Act;
- any request, notice or direction under the Act; or
- a serological clearance or other medical examination under the Act;
- it is an offence to provide false or misleading information in relation to a certificate of fitness, serological clearance or other medical examination report provided under the Act.