Your Name
Your Email
Your Phone # (With Area Code)
Current Rank
Date of Last Promotion
Name and Contact Information of the Person or Organization that issued the Rank
Type YES if you can provide proof of certification
Type YES if you understand and agree that you shall not be compensated for activities connect with the Kajukenbo Hui
Type YES if you understand and agree that you shall not be reimbursed by Kajukenbo Hui for any incurred expense
Type YES if you understand and agree that you shall not conduct any financial activity on behalf of Kajukenbo Hui
Type YES if you agree that an organization may provide black belt rank promotions based on objective criteria