OHTC MARTIAL ARTS ASSOCIATION
Application for Chapter Instructor and Black Belt
Registration
Application Fee: $40.00
Please specify which art(s) you are applying:
Tae Kwon Do []
Hap Ki Do []
Moo Sa Sool []
Soo Bak Ki []
Shaolin Chuan []
Tai Chi Chuan []
Wu Shu []
All Chapter Instructors must fulfill the following
requirements:
Instructor Information (if applicable)
Instructor's Name: ________________________________
Degree: ________________
Name of School:
______________________________________________________________________
Address:
____________________________________________________________________________
Telephone: ________________________ Fax:
____________________________________
E-mail: ___________________________________________________________
Master's Information
Master's Name:
___________________________________________Degree:____________
Root:___________
Name of School:
________________________________________________________________________
Address:
________________________________________________________________________________
Telephone: ____________________________________ Fax:
______________________________________
E-mail: _____________________________________________________________
Personal Information
Name:
___________________________________________________
Address:
____________________________________________________________________________
Telephone (Office): __________________________________ Fax:
____________________________________
Telephone (Home): _____________________________ E-mail:
______________________________________
Occupation:
______________________________________________________________
Position: ________________________________________________________
Name of Business: _________________________________________________________
Address:
______________________________________________________________________________
Married [] Single []
Widowed [] Divorced/Separated []
# Children []
Physical Record
Height: _____________ Weight:
____________
Color Hair: ____________ Color Eyes:
_____________
Education
High School:
_______________________________________________________________
College:
_______________________________________________________________________
Degree: 2 year [] 4 year []
Master's [] Doctoral []
Other []
1. Have you ever been convicted of a felony or crime involving
moral turpitude?
Yes [] No []
Explain: _______________________________________________
2. Have you within the past three years had, or currently have
any mental illness, drug or dependency problem?
Yes [] No []
Explain:
_____________________________________________________________________________
I authorize investigation of all statements contained in
this application. I understand that misrepresentation of facts calls for
immediate dismissal. By entering your name below your are submitting
your authorized signature.
Signature:
________________________________ Date:
________________________________
Please Submit Completed Registration Form With Payment
Information or Print Completed Form and Mail to OHTC With Registration
Payment.
Do Not Fill In Any Information
Below This Line
Approved By:
Date:
Record No: Root Code:
Chapter Code:
Thank you for your registration. If
you have any further questions, please feel free to contact us by email or by
phone:
OHTC Martial Arts
Association
4724 West, Lovers
Lane, Dallas, TX 75209
214-358-0018
E-mail: sales@ohtc.com
