RO INSLER TAEKWONDO

973-777-4741 – Fax 973-777-4742 – TKDteach2@aol.com – www.RoInslerTKD.com

Mailing address: 23-26 Berkshire Road, Fair Lawn, NJ 07410

ADVANCED TEST APPLICATION – RED BELT TO CANDIDATE-FOR-BLACK BELT

Please print out, complete and return this form immediately with your payment. (See bottom of form**

Write your name below*, as you want it to appear on your certificate:

*_______________________________________________

Student Info:
_____________________________	_____________________________	__________________________
Last Name	First Name	M. I. - Nickname
______________________________	_____________________________	__________________________
Address	Town	State - Zip
_____________________________	_____________________________	__________________________
Date of Birth	Home Phone #	Work Phone #
Emergency Info:	_______________________________ Student’s E-mail Address
1_____________________________	2_____________________________	3___________________________
Spouse/ Mother / Guardian	Father / Guardian	Other Emergency Contact Name
1_____________________________	2_____________________________	3___________________________
Work Phone #	Work Phone #	Emergency #
1_____________________________	2_____________________________	3___________________________
E-mail	E-mail	Relationship to Student
Promotion Info: (to be completed by Instructor)
_____________________________	_____________________________	___________________________
Present Rank & Belt Color	Rank & Belt Testing for	Color / Belt Size Needed / Tape
_____________________________	_____________________________	___________________________
Test Date & Time	Certificate I.D. #	Grade / Comments

**TEST FEES**

___ RED, $40 ___ HIGH RED, $40 ___ BROWN, $50 ___ CANDIDATE. $75

**Deduct 10% each for family discount

Payment in CASH preferable - or Check payable to “CASH”

Promotion Test Location:

___ Thomas Edison School Gym, 37-01 Fair Lawn Ave., Fair Lawn, NJ 07410

___ Fair Lawn Jewish Center, corner of Manor Ave. & Walsh Pl, Fair Lawn, NJ 07410

___ Fair Lawn Heavy Rescue, 16-01 Romaine St., Fair Lawn, NJ 07410

___ ________________________________________________________________________

_____________________________________________________

Student’s Signature (age 18 & up) or Parent’s Signature (17 & under)