Name (last) (first) (initial) (telephone)

Address City State Zip

In case of emergency notify (telephone)

Do you have any physical problems in take this test?

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

Start Date Current Rank Select your rank White Yellow Yellow Green Low Green High Green Low Blue High Blue Low Red 4 Low Red 3 High Red 2 Last Promotion Date

Training Location Nationality

I understand that the promotion fee is Select the belt level you are testing for. $20.00 - Yellow Belt $25.00 - Yellow Green Belt $30.00 - Low Green Belt $35.00 - High Green Belt $40.00 - Low Blue Belt $45.00 - High Blue Belt $50.00 - Low Red Belt 4 $10.00 - Low Red Belt 3 $55.00 - High Red Belt 2 $10.00 - High Red Belt 1 and I have agreed to make full payment. I understand that the fee is not refundable. Please make checks payable to Golombisky Institute.

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 this test.

If you are under 18 years of age, please have your guardian sign below.

APPLICANT / GUARDIAN SIGNATURE: _________________________________________________________