KONAN JUDO ASSOCIATION

KYU PROMOTION REGISTRATION RANK RECOMMENDED:

LAST NAME FIRST MIDDLE

NAME ( Mr. Mrs. Miss) :

ADDRESS: CITY STATE: ZIP

AGE: BIRTH: HEIGHT: WEIGHT: USJF #:

OCCUPATION: FIRM:

EDUCATION - GRADES COMPLETED

AFFILIATION - DOJO PROMOTION HISTORY

INSTRUCTOR RANK

ENTRY DATE IKKYU

FAVORITE WAZA NIKYU

KATA COMPLETED SANKYU

YONKYU

MAJOR SHIAI RECORD - AWARDS - CONTRIBUTIONS GOKYU

DATE EVENT OPPONENT RANK RESULT ENTRY

KONAN ENDORSEMENT

DATE RECEIVED:

REVIEWED BY:

FEE PAID:

COMMENTS:

NUMBER ASSIGNED:

ENDORSEMENT:

RECOMMENDED BY:

DATE: SIGNED: TITLE:

DATE

9-2000 KONAN JUDO ASSOCIATION FORM #KYU20