To: Chairman for MASK Black Belt Council (BBC) The Examination Day: ______________ Venue: ____________________________ DAN : Shodan [ ] Nidan [ ] ------------------------------------- Please fill in the following information --------------------------------------- NAME Family Given Middle (Mr. Mrs. Miss) _____________________________________________________ Age: : ________ Date of Birth (Y/M/D) _________/______________/_______ NRIC: _______________________ Present Address : __________________________________________________________________ Telephone Nos.: (H) _________________________ (HP) ______________________ Occupation or Profession (Details of present employment or school) (Name) _____________________________________ (Dept) __________________________ (Add) ___________________________________________________________________________ Telephone Nos.: (O)____________________ (E-mail)__________________________ When did you join MASK (year) _____________(month) ______________ (day) ____________ How long have you been doing "SHUGYO”? (Training of your soul, techniques, physique) : _______________ year(s) and ____________ month(s) History of KYU & DANI
A Guarantor of your history about Karate-Do (Your Sensei) Name: _________________________________________ Relationship: _____________________ Address The State that apply for your DAN Grading Name of the State & Location: Name of the President: __________________________ Signature of the President ______________
Your Compulsory KATA (ONE) [ ] Bassai-Dai [ ] Seienchin Your favourite KATA (ONE) (Please follow the official list of MASK Syllabus)___________________ _________________________________________________________________________________________________________ Application Form should reach to MASK BBC Chairman or MEC Director 6 (Six) months before the actual date of the examination. |
