Name:(Last)                                                        (First)                                                (Initial)                        (Tel)

Address:                                                                            (City)                                              (State)            MI     (Zip)

In case of an emergency notify:                                                                                                                  (Tel)

Do you have any physical problem(s) in taking the test?___________________________________

Age:                           Date of Birth:                                         Weight:                         Height:                   (ft)                    (in)

Start Date:                                                Current Rank:                                               Last Promotion:

Training Location:                                                                                                           Nationality:

I understand that the promotion fee is $ ___ and I have agreed to make full payment. I understand that the fee is not refundable.

In consideration that a risk may be involved at the test I release the Association President, Master Instructors, Members and Authorized Guests from all responsibilities and claims for injury I may receive while taking the test.

If your are under 18 years of age, please have your guardian sign below. APPLICANT / GUARDIAN SIGNATURE:_____________________________________________________

Test Fee:         $______________ ATTENDANCE:          Excellent      Good         Fair              Poor

Amt. Pd:          $  _____________ PERFORMANCE:             Excellent      Good         Fair              Poor

Balance:          $ ______________ SPIRIT:                      Excellent      Good         Fair              Poor

Paid Full:               YES / NO 

Rec. Initial:                                                    Recommended by: William Golombisky, Sa Bum

Instructor's Signature:                  Dated:

TEST EVALUATION:

Form:                      Basic Kicking:                                  1-Step:                Free Fighting           |                |

Break:                                         Tae Kwon Do Spirit: _________________________________

Recommendations:________________________________________________________________

Make checks payable to: Golombisky Institute