BODOKI-RYU NINJITSU DOJO / P.O.Box: 535, Bronx, New York. 10451-0535
( A
One TimeOffice-Startup Fee / $125.00 ( No Exceptions )
RANK CERTIFICATION APPLICATION:
First Name:__________________________ Name:__________________________
Address:____________________________City:________ State:____________ Zip:______
Apt:_____ Sex:_________ Age:____ Home Phone:_____________ Date Of Birth:_____
Email Address:____________________
What is your Website URL:_____________________
Are You A Member Of Any Organization: If Yes, ____________________________________
Give Registration Number:________________________ Martial Arts History / on back of page.
School / Dojo: ________________________________________________________________
Please Give Us The Following Information;
Inst. Name,________________________________Title,________________________________
Instructors Rank.___________________________ Rank Obtained From School/Dojo:
_________________Years Of Study:____________ Date Of Rank:________________
Weapons Proficient In: __________________________________________________________
Knowledge And Ability: [ ] Excellent: [ ] Good: [ ] Fair: [ ] Poor:
Physical Shape: [ ] Excellent: [ ] Good: [ ] Fair: [ ] Poor:
Are You Under Any Of The Following:
[ ] Independent Member-No Instructor. [ ] Self Trained / No Instructor.
Status: { Please check one only }.
[ ] Rank Certification Program / For Rank of: _______________________________ ( $ )
[ ] would like to join BDK-Rank Program for black belt membership. ( we need a copy of your rank ).
Attention: all payments payable to: soke: angel m. guerra ) send to our main
office: BDK / P.O.Box: 535, Bronx, New York. 10451-0535
Sign Below:
I______________________________________________________
hereby submit;
that the information verifiable certification of that rank from a credible school or organization.
Sign your name:
___________________________________________________Date:_______________
