Black Belt Grading Re-Test Application

Application form
This form is for members who have received a Pass Incomplete result at their black belt grading, and now wish to complete their grading. This form should be completed by the candidate at least two weeks prior to the proposed re-test date, and they should have already gained the permission of the examiner.
Name:
Name of your Club:
Address:
Email address:
Phone:
Current Rank:
Date of Birth:
Age:
Date of Re-test:
Proposed examiner for re-test
Areas need to be re-tested
Fee:	Fee is $57.50 - pay now into bank account: ASB 12-3035-0746009-00. Use your surname in the reference area.
Your Bank Account:	This is for any refunds if you cancel your re-test.

Other information or questions:
Please Verify :
Conditions I agree not to hold International Taekwon-Do or the organisers responsible for any injury I may sustain during the event. I have paid the re-test fee into the account noted above. I understand that I have one chance only at this re-test, after which if unsuccessful I must re-apply for the whole black belt grading. I have my instructors consent and the agreement of the examiner to sit this re-test. I agree to notify the organisers at least 48 hours in advance if I am for any reason unable to attend, so that someone can take my place. If I do not cancel I understand I am obligated to still pay the application fee.
I agree to the conditions listed above and submit my application