National Headquarters

187 Monte Carlo Way, Danville, California  94506  U.S.A.

TEL.: (925) 736-3008,  FAX: (925) 736-2429　

　

The clenched fist design , the mark “Goju-Kai”, and ｢剛柔会｣(in kanji) as printed here on the top are legal service marks registered with the United States Patent Office by Norimi Gosei Yamaguchi. To duplicate these service marks by way of printing, embroidering and founding or to display them in public without authorization may constitute service mark infringements and may be subject to lixiviation . Please refer to ” About Goju-Kai Insignia"

　

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N. Gosei Yamaguchi, Chairman

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

　

　

　

　

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          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:                              

　

　

　

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NATIONAL MEMBERSHIP CARD NUMBER:                                                                  

　

   

　

　

 

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(For Office Use Only)

Fees Received _______________

Date Issued _________________

Diploma No.