Black Belt Promotion Test Registration Form | 2nd Poom / Dan Promotion Test | Black Belt 2nd Poom/Dan Promotion Test Information Test Date: December 4, 2021 Time: 3:00 PM - 6:00 PM Registration Deadline: November 6, 2021 (Complete Regstration form including payment) Belt Promotion Test Registration Fees: 2nd Dan/Poom $700.00 Plus Tax Adidas Black/Poom Belt Dobok Included if test is completed with a passing grade Adidas Black/Poom Belt Included if test is completed with a passing grade Kukkiwon Certificate Application Included if test is completed with a passing grade Please complete the leadership and instructor subsidy form to see if you qualify for a subsidy for your promption test fee. A maximum of $200.00 can be applied if all requirements are fulfilled. Test Applicant Information First Name * First Last Name * Last Name In Hanja/Hangul (Chinese/Korean) * You may put both if you know the translation Membership Number * Date of Birth * Age Address * Address Street Address Street Address Apt./Building/Suite # Apt./Building/Suite # City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Email Address * Phone * Dobok Size * Please put the desired dobok size. Poom Uniform will be used for 14 years old and Under | Dan Uniform will be used for 15 years old and older Belt Size * Current Size on Belt Digital ID Photo (Kukkiwon Certificate Application) * Drop a file here or click to upload Choose File Maximum upload size: 268.44MB Leadership Program / Instructor Program Subsidy Application Form Drop a file here or click to upload Choose File Maximum upload size: 268.44MB Choose In-person payment if application form is submitted. An seperate email will be sent to you if the application is approved. Test to 2nd Poom / Dan Promotion Test Fees Payment Method * Online Payment In-Person Payment Black Belt 1st Dan/Poom Test Requirement * Minimum 1 Year of regular class training after your Black Belt 1st Poom/Dan Test Last Promotion Test Date * * Minimum 50 Leadership/Vounteer Hours after your Black Belt 1st Poom/Dan Test Leadership/Volunteer Hours * * Referee Seminar (Club Level or Provincial Level) and Passing a Written Test Referee Seminar Date * Emergency Contact Information Emergency Contact Name * Emergency Contact Name First First Last Last Relationship to Member * Parent Legal Guardian Other Relationship to Member Emergency Contact Phone Number * Waiver Information I hereby give permission for myself/my child to participate in Jeon Eui Taekwondo Black Belt Promotion Test. I understand that there is no refund on black belt promotion test fee. For extenuating circumstances, the black belt test may be postponed by providing written notice within 48 hours after the test. Only one postponement will be allowed and it must be re-scheduled within one year. Having read and understood all the information on this form, I hereby allow myself/my child to attend Black Belt Promotion Test. The Waiver Forms that I have signed at Jeon Eui Taekwondo will also apply to the Black Belt Promotion Test. Signature * Clear Sign by parent or legal guardian if under 19 years of age Date * Payment Total Test to 2nd Poom / Dan Promotion Test Fees Subtotal GST (5%) Online Processing Fees (3%) Total If you are human, leave this field blank. Submit
