Application for Dan Certificate
| Name
| Ivan
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| Ivanov
| Mr./Ms.
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| First Name (1 only)
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| Family Name (1 only)
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| Address
| Bluhera str. 123-45
| Samara
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| Russia
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| Street
| Town
| Zip code
| Country
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| E-mail
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| Date of Birth:
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| Sep.
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| Age
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| date
| month(in word)
| year
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| Years
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| Nationality
| Russian
| Birth place
| Samara
| Russia
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| (as passport)
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| Town
| Country
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| Occupation
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| Education
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| Here glue
Passport size photograph
To send to ITF
passport size photo,
gripped on this paper
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| Present ITF Dan Certificate Nr:
| RU-1-1234
| Dojang Plaque Nr.
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| Dan applied for:
| II
| Date of last Dan grading:
| Apr. / 2010
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| month / year
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| Personal History and Thesis
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| Title of thesis
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| (Only required for promotion to 4th Dan)
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| Courses taken: Course Cert. Nr.
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| Signature:
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| Date of grading:
| /
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| Place of grading:
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| dd /
| mm(in word)
| / yyyy
| Town
| Country
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| Instructor:
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| /
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| /
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| (Full Name)
| (Int’l Instructor Certificate Nr.)
| (Signature)
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| /
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| /
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| (E-mail)
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| (Main plaque Nr.)
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| (Branch plaque Nr.)
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| Examiner:
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| /
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| /
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| (Full Name)
| (Int’l Instructor Certificate Nr.)
| (Signature)
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| /
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| (E-mail)
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| (Main plaque Nr.)
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| (Branch plaque Nr.)
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| President/ Authorized deputy:
| Yury Kalashnikov
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| itf-taekwondo@yandex.ru
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| (Full Name)
| (E-mail)
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| Date:
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| Signature:
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| (NGB stamp)
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2015-06-26
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