Connecticut Judo, Inc

CONNECTICUT JUDO, INC. RECOMMENDATION FOR PROMOTION

USJI Membership number (REQUIRED) ______-______

(1) Name ______(2) Gender M F (3) Date of Birth ______

(4) Address ______(5) City ______

(6) State ____ (7) Zip ______(8) Last Rank ______(9) Date of last promotion ______

(10) Location of promotion ______(11) Promoted by ______

(12) Club ______A copy of the last certificate must by attached.

SENIOR  JUNIOR  (13) Recommendation for promotion to ______(14) Date ______

(15) Recommended by ______(16) Auth.No.______

(17) Time in Grade ______to ______Years. Months ______

(18) Points:Competitor  (Copy of record book required.) ______

Non-Competitor  (Copy of record book required.) ______

(19) Examinations: General Information and Vocabulary ______

(20) Practical Evaluation ______needed acquired (21) Examiner’s Recommendation  PASS  FAIL

(22) Promotional Examination conducted by: (23) Date ______Print name Rank Auth. Number Signature

1. ______

2. ______

3. ______

4. __ (Rev.05/2003) For official use only: Received by Secretary (date) ______Rank: Granted  Rejected  Certificate made up:______Certificate number ______Certificate sent ______

Chairman’s signature ______Reason: ______