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:

• High School Diploma, Equivalent or Higher

• No Criminal Conduct or Immoral Behavior

• No Drug or Alcohol Abuse

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:

 

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Method of Payment

Check
Credit Card 

Check Information:
If paying by check, please enter check amount and check number .

Credit Card Information:

Check One:American Express Visa MasterCard
Name On Card: 
Card Number:    For your security, provide this information by phone or mail.
Expiration Date:  For your security, provide this information by phone or mail.

I prefer to call in my credit card number over the phone. (Order will be processed as soon as payment is received.)

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Please enter your comments here.

 

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:

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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