Application for Dan Certificate

International Taekwon-Do Federation I.T.F.

Draugasse 3, 1210 Vienna, AUSTRIA Tel. (+43-1) 292 84 67 Fax (+43-1) 292 55 09 E-mail: [email protected] [email protected] Website: www.itftkd.org

ITF use only APPLICATION FOR DAN CERTIFICATE

Name Ivan / Ivanov Mr./Ms. First Name (1 only) Family Name (1 only) Address Moskovskaya str., 1-23 Moscow 123456 Russia Street Town Zip code Country E-mail [email protected] Date of Birth: 01 / Feb. / 1970 Age 38 date month(in word) year Years Nationality Russian Birth place Moscow Russia (as passport) Town Country Occupation Engineer Education Higher

RU-1- Present ITF Dan Certificate Nr: 1111 Dojang Plaque Nr. 0001 Here glue Dan applied for: II Date of last Dan grading: Feb. / 2005 Passport size

month / year photograph Personal History and Thesis To send to ITF passport size photo, (Only required for promotion to 4th Dan) Title of thesis gripped on this paper Courses taken: Course Cert. Nr.

Signature:

Date of grading: 15 / Jan. / 2008 Place of grading : Moscow Russia dd / mm(in word) / yyyy Town Country

Instructor: Petr Petrov / 2222 / (Full Name) (Int’l Instructor Certificate Nr.) (Signature) [email protected] / 0001 / (E-mail) (Main plaque Nr.) (Branch plaque Nr.) Examiner: Sidor Sidorov / 3333 / (Full Name) (Int’l Instructor Certificate Nr.) (Signature) [email protected] / 0002 / (E-mail) (Main plaque Nr.) (Branch plaque Nr.) President/ Authorized deputy: Yury Kalashnikov / [email protected] (Full Name) (E-mail)

Date: Signature: (NGB stamp)