Application for Promotion Test

Nationality (Citizen) First Name Middle Last Date of Birth INDONESIAN LOTUS PALACE BLOK Y 7 NO: 8,PANTAI INDAH UTARA Address II,PANTAI INDAH KAPUK,PENJARINGAN JAKARTA UTARA Year Month Day Tel e-mail

+62.21..55963397 Yuti2011@gmail.com
() Dan/Poom applied for Sex

1 ID-size photo attach with paste

() Current Grade () Dan Certificate No. Date of Issue

() . I submit this application to the Promotion Board of KUKKIWON for a Promotion Test. Date of application :

..

: . Applicant

() . I honestly recommend the above person as a well-qualified applicant for the promotion test of Dan/Poom grades. country INDONESIA / Name of Association/Dojang YUTI TRAINING CENTRE

Recommended by

GRAND MASTER LIOE NAM KHIONG

/ Address of Association/Dojang Tel/ Fax/ e-mail

LOTUS PALACE BLOK Y 7 NO: 8,PANTAI INDAH UTARA II,PANTAI INDAH KAPUK,PENJARINGAN JAKARTA UTARA +62.21.55963397/+62.21.55963399/yuti2011@gmail.com

Recommender`s Dan Certificate No or Date of Birth

8th DAN KUK KI WON 05001949

To: President KUKKIWON(World Taekwondo Headquarters)

1. Name : The name must be printed or typed. 2. Dan Certificate No : The current Dan number must be the one given by Kukkiwon or WTF. 3. Recommended by : The recommender of applicant should ensure that no false statement will be found in the application, otherwise, the Dan will be nullified even after its issuance and recommender will not be allowed to make further recommendations. 4. Applicant who staying abroad shall attach a document to confirm actual residence in the foreign country for more than 6 months. 1. : 2. : . 3. : , . 4. 6 .

NOTE