Application Form for Black Belt Grading International Federation of Karate

							      Application Form for Black Belt Grading
        International Federation of Karate
Country Name

Country Representative

                          Section A - General Details
(Please PRINT Clearly)

A1. Name of Student                     Family Name (Surname)                 Given Name (Christian Name)



A2. Date of Birth                    Date      Month        Year                 Age


A3. Address




A4. Organisation and DO JO
where student trains

A5. Number of years training                           A6. IFK Membership
in Kyokushin Karate                                    Card Number

                                        Official Use Only

A7. Date of Examination                                A8. Place of
                                                       Examination

A9. Result of Examination                              A10. Length of Belt
                                                                                                       Cms

A11. Senior Examiners Name and Grade            OR
                                                                 Examination Committee



    Signature



A12. Organisation or Country Stamp                Please attach 2 photos
                                                       3cmX4cm




                                                                           Photo 1           Photo 2
                                          Section В - Students Details
Please note: If there Is Insufficient space to list all your tournaments/courses/qualifications please continue on a separate sheet of paper and attach
to your application.


B1. Have you trained in any other martial arts? If yes please give details




B2. Please list details of National and International Courses you have attended (during the past з years)
 Number                                           Name of Course                                                      Date                           Location




B3. Please list details of National and International Tournaments you have taken part in.
 Number                                           Name of Course                                                      Date                           Location




B4. Please list details of Judging/Refereeing qualifications
 Number                                           Name of Course                                                      Date                           Location




B5.Do you instruct? If so at what level


B6. Position held in dojo, if any?




B7. Do you have any National/International Coaching Qualification? If so please give details.




B8. Please give any First Aid Qualification held and date achieved.




B9. Do you have any physical disability which restricts the performance of any technique? If so please
give details and a Doctors letter (An injury is not a disability and therefore cannot be taken into consideration during Grading)



B10. Students Signature                                                                                               Date
            Section С - Instructors Recommendation
C1. Instructors Name


C2. Instructors Grade                               C3. Instructors IFK
                                                    Membership Card No

C4. Instructors Address and
Telephone/Fax number




C5. Current Grade of Student and date achieved                   Previous Dan Grade
                                                                 Certificate Number

C6. Please give details of students dojo attendance during the past 12 -18 months




C7. What assistance does the student give to the organisation
          (e.g. Administration, organisational,, demonstrations etc)




C8. Please give students sports biography/history




C9. Instructors Signature of recommendation


C10. Date