RO INSLER TAEKWONDO

973-777-4741 Fax 973-777-4742 RoInslerTKD@gmail.com www.RoInslerTKD.com

Mailing address: P.O. Box 8066, Saddle Brook, NJ 07663-8066

TEST APPLICATION FOR:

CANDIDATE-FOR-BLACK BELT - JUNIOR BLACK BELT - BLACK BELT -

SELF-DEFENSE BLACK BELT - POOM TO DAN BLACK BELT RE-CERTIFICATION

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

*_______________________________________________

 


Student Data:

__________________________________

Last Name

 

________________________________

First Name

 

_____________________________

M. I. - Nickname

_____________________________ Date of Birth

_____________________________ Home Phone #

__________________________

Work Phone #

Emergency Info:

. .

1. Spouse's or Parent's Name

 

. .

2. Spouse's or Parent's - Cell #

 

. .

3. Other Emergency Contact Name

. .

1. Spouse's or Parent's Email

. .

2. Other Parent's Email

. .

3. Other Emergency Contact's Cell #

Promotion Info - For Official School Use Only - Completed by Instructor

. .

Present Rank & Belt Color

. .

Rank & Belt Testing for

. .

Color / Belt Size Needed / Tape

. .

Test Date & Time - Fee

. .

Certificate I.D. #

. .

Grade / Comments

TEST FEES

* Candidate for Black Belt, $75

* Belt Re-Certification, $100

* Self-Defense Belt, $150

* 1st Poom/Jr. Black Belt, $150

* 2nd Poom/Jr. Black Belt, $250

* 3rd Poom/Jr. Black Belt, $350

* 1st Dan Black Belt, $250 (age 15+)

* 2nd Dan Black, $350 (age 17+)

* 3rd Dan Black, $450 (age 20+)

 

* 4th Dan Black, $550 (age 25+)


Embroidered belt included (names in English only) - Additional fee incurred for stripes, extra long names, etc.

**Test fees subject to change depending on location, number of students testing, black belt panel, embroidery and other administrative fees, etc.,

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

 

(Also see Candidate/Black Belt Test Requirements - print both pages back-to-back when submitting for testing)