Black Belt Grading Form

REQUEST FOR DAN REGISTRATION

NAME ______________________________

ADDRESS ______________________
______________________
______________________

TELEPHONE ______________________

REGISTERING FOR ____ DAN DATE OF EXAMINATION ____________________
EXAMINER _______________ INSTRUCTOR _____________________________
CLUB NAME ______________________________________________________________
REGION & COUNTRY _______________________________________________________

PERSONAL INFORMATION:

DATE OF BIRTH __________________      SEX ____________
HEIGHT _______ FT _____ IN ________  cm WEIGHT _________ LBS /KG
OCCUPATION ______________
LAST SCHOOL OR COLLEGE _______________________ DEGREE RECEIVED ________

KARATE HISTORY:

When did you begin karate practice?  YEAR ________ MONTH _______________

PREVIOUS DAN REGISTRATIONS:
               DATE OF EXAM    REG.  NO.                   DATE OF EXAM     REG.  NO.
1ST DAN ______________ ____________ 5TH DAN ______________ ____________
2ND DAN ______________ ____________ 6TH DAN ______________ ____________
3RD DAN ______________ ____________ 7TH DAN ______________ ____________
4TH DAN ______________ ____________ 8TH DAN ______________ ____________

I REQUEST THAT MY RANK BE LISTED IN THE REGISTER OF THE JAPAN KARATE ASSOCIATION.
I PROMISE TO UPHOLD THE STANDARDS AND HONOR OF THE JKA AND THE ISKF.

STUDENT'S SIGNATURE _____________________________________________________________
_________________________________________________________________________________

FOR EXAMINER'S USE ONLY 

DAN RANK AWARDED: ______________ EXAMINER'S SIGNATURE: __________________________ 

PROMOTION BY: (CIRCLE ONE)   EXAMINATION        RECOMMENDATION     HONORARY
REMARKS: