United States Martial Arts Institute, International

Certification and Rank Awarding Program

JUDO BLACK BELT CERTIFICATION APPLICATION

Staple Two ID Photos Here

Personal Information

Name: __________________________________________________________________

Address: _________________________________________________ Apt:__________

City: ________________________________ State: ______________ ZIP:___________
Country: ________________________________________________________________

Date of Birth: ________month ________day ________year Gender: __________

Home Phone: (_______)_______________ Work Phone: (_______)______________

e-mail, or website: ______________________________________________________

School/ Club Name: _____________________________________________________

School/ Club Address: ___________________________________________________

City: ________________________________ State: ______________ ZIP: __________

Country: ________________________________________________________________

Checklist

• Rank Apply for ______ Degree Black Belt in JUDO
• Certification Fee $______ Amount for your Rank Certification
• Copy of your certificate (if required)
• Resume
• Brief history of personal martial arts training
• Video tape or DVD for evaluation
• Make a check payable to: San Yoon

Send to:          Grand Master San Yoon

          USMAI, International

                     8524 Burnet Rd. #1227

      Austin, TX 78757 USA