United States Taekwondo Association
87 Stonehurst Drive
Tenafly, NJ 07670 USA
www.usta.info ~ e-mail:
Application for Membership
Name ______Sex ___ Date of Birth ______Age ____
Address______
City ______State ______Zip ______
Home Phone ______Work Phone ______Cell ______
Employer______Occupation______
Martial Arts Background
Present Rank (grade/belt/dan/degree) ______When Received ______
Instructor & His/Her Rank ______
School Name ______
Address ______Phone ______
List Promotions In Order of Highest Rank
Rank & Belt/Promotion Date/School/Instructor & Rank
1. ______
2. ______
3. ______
Forms Trained In
Palgwe ______Taegeuk ______WTF Dan ______ITF ______Tang Soo Do______
Forms Mastered ______
Please Check If You Wish to Be Certified By the United States Taekwondo Association
Rank Certification: Non Black Belt ______Black Belt ______Testing & Promotion ______
School/Club Affiliation ______Instructor Certification ______
Please Place Any Additional Information On the Reverse Side
Fees (Circle Choice):
One Year Membership: $30.00 ~ Three Year Membership: $50.00
Foreign Add $10.00 for Shipping
Signature of Applicant/Guardian______Date ______