Rank Certification

APPLICATION FOR RANK CERTIFICATION
If you would prefer, download and fill out the application HERE
Name*
First Last
Gender*
- Male
- Female
Birth Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Enter Email Confirm Email
Phone*
Present Rank Information
Choose one*
- Color Belt
- Black Belt
Date Rank Recieved
MM slash DD slash YYYY
Present Rank Instructor Information
Instructor Name*
First Last
Instructor Rank*
School Name
School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Desired Rank*
- Color Belt
- Black Belt
Digital Signature and Agreement*
- I certify the accuracy of the above information and agree to abide by the rules of the USTA.
USTA Membership #*
Rank Certification #
Color Belt Certification Fee: $25
Black Belt Certification Fees:
1st Dan - $300
2nd Dan - $350
3rd Dan - $400
4th Dan - $450
5th Dan - $500
6th Dan - $550
7th Dan - $600
8th Dan - $650
Please make check payable to Chosun Taekwondo Academy and send to:

USTA c/o Chosun Taekwondo Academy
60 Galloway Road
P.O. Box 721
Warwick, NY 10990
Examiner’s Use Only (see notes)
Examined By
Examiner's Rank
Date
USTA Instructor Certification #
USTA Rank & Certification #
School Name & Address
->
Additional Comments
->
Rank Applicant Promoted To
Examiner’s Signature
Notes:
1. Testing/Certification Fees- Black Belt fees Vary with Rank, Please Call, Write or e-mail
2. Black Belt Certification Requires 2 Passport Photos (2 x 2) of Yourself
3. If applying for Certification Directly to the USTA Due to the Absence of a Certified Examiner, also enclose:
A. Supportive Documents of Your Present Rank (a copy of Dan Certificate)
B. Resume Detailing Your Martial Arts Training, Rank and Achievement History
4. Non-Black Belt (all levels of color belts), Rank & Certification Fee: $25 (enclose a copy of gup/color belt certification).

APPLICATION FOR RANK CERTIFICATION

Present Rank Information

Present Rank Instructor Information

Examiner’s Use Only (see notes)