GOJU-KAI KARATE-DO, USA

NATIONAL HEADQUARTERS

187 Monte Carlo Way, Danville, California, 94506  USA

Telephone: (925) 736-2429  FAX: (925) 736-2429

 

APPLICATION FORM FOR DIPLOMA

 

GREEN BELT     (6th, 5th, 4th kyu)………… $10.00

BROWN BELT    (3rd, 2nd, 1st kyu)  …….. $15.00

BLACK BELT  

SHODAN HO ........$20.00

SHODAN .............. $30.00

NIDAN HO .......... $40.00

NIDAN ...................$50.00

SANDAN HO ....... $60.00

SANDAN .............. $70.00

YONDAN ..............$90.00

GODAN ................. $110.00

 

 

NAME                                                                                       ,                        

          Last                                              First                                       Middle 

 

HOME                                                                                                                            

ADDRESS:  Street No. & Street       City                                      State                   Zip

 

TEL:                            BIRTH DATE:                         DIRECTOR                                          

                                                                                                     (Name of Instructor)

 

DOJO ADDRESS:                                                                          TEL:                                  

 

 

RANK APPLYING FOR:                                 DATE RECEIVED:                                        

                                                                             (Date of Examination )

 

INSTRUCTOR'S SIGNATURE:                                                   DATE:                              

 

APPLICANT'S SIGNATURE:                                                     DATE:                                

 

 

NATIONAL MEMBERSHIP CARD NUMBER                                                                   

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(For Office Use Only)

 

Fees Received _______________

Date Issued _________________

Diploma No.