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

JUNIOR BLACK BELT– BLACK BELT – SELF-DEFENSE BLACK BELT

 & BLACK BELT RE-CERTIFICATION TEST APPLICATION

Please print, complete entire form if there are chaand return this form immediately with your payment. (See bottom of form**)

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

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Student Data:

 

 

 

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Last Name

First Name          

M. I.          -          Nickname

 

 

 

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Date of  Birth

Home Phone #

Work Phone #

 

Emergency Data:

 

 

 

 

 

 

 

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Spouse/ Mother / Guardian

Father / Guardian

Other Emergency Name / Tel. #

 

 

 

 

Promotion Data: (to be completed by Instructor)

 

 

 

 

 

 

 

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Present Rank & Belt Color

Rank & Belt Testing for

Belt Size Needed

 

 

 

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Test Date & Time

Certificate I.D. #

Grade / Comments

Payment in CASH or Check payable to: CASH or ROSEANNE M. INSLER

 

BLACK BELT TEST FEES ** (Embroidered belt not included in test fee, see +)

 

R Poom to Dan Re-Certification, $100                    * Self-Defense Black Belt, $150

* First Poom/Junior Black Belt, $150                    * First Dan/1st Degree Black Belt, $250

* Second Poom/Junior Black Belt, $200               * Second Dan/2nd Degree Black Belt, $300

* 3rd Poom/3rd Degree Jr. Black Belt, $300          * Third Dan/3rd Degree Black Belt, $400

* Embroidered Belt, Add $35 or more (price subject to # of letters, font, stripes, etc., typically not higher than $55)

**Test fees are subject to change depending on location, number of students testing, black belt panel, etc.,

 

 

 

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