MI Referee Seminar Participant Application by 8h5Eu4

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									                                             Seminar Information
Seminar Date: Feb 28, 2009              Seminar Host:       Michigan Sport TKD, Inc
Seminar Fee: $55.00                     Seminar Instructor:        Mr. Ron Rose
                                            Participant Information
All attendees are required to wear a Taekwondo Dobok for seminar.
First Name:                                                 Last Name:
Address:
City:                                                                      State:                Zip:
Phone:                                                      Fax:
Email:
Date of Birth:                                        Age:                          Gender:        M     F
Please Circle One          U.S.           U.S.       Other Please
                          Citizen       Resident     List:
USAT Membership #:                                        Referee Classification:
Black Belt Rank:                                   Black Belt #:
All participants must be at least 16 years old, 2008 USA Taekwondo athlete and/or referee member, provide proof
of 1st degree black belt certification or higher, and pay seminar fee in order to be eligible to receive Referee
Certification.
I hereby pledge to accept the Rules and Regulations of the USAT and the Referee Development Program.
Signature:                                                                               Date:
Please check Payment Type (Personal and Business checks are not accepted):
    Cashier’s Check/Money Order       Visa        MasterCard       Discover                   American Express
Credit Card #:                         Expiration Date:              Security Code (Located on back of card):
Print Name of                                Zip Code of
Card Holder:                                 Card Holder:                Signature:
                                       For Seminar Instructor Use Only
Current Referee Level:                Recommended Certification or Upgrade:
If no certification or upgrade is recommended please give explanation:

								
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