TAEKWONDO MALAYSIA (WTF)

SENIOR UP-GRADING

DATE : 19TH DECEMBER 2022 (MONDAY)

TIME : 8.00 PM
VENUE : MULTI DYNAMIC MARTIAL ARTS GYM (MBW)
1, JALAN 53, PEKAN KEPONG ,52100 KUALA LUMPUR

NO NAMES FEES REG BB NO PRESENT DAN/POOM

DAN/POOM APPLIED

Fees
3rd Dan/Poom to 4th Dan/Poom
4th Dan to 5th Dan
5th Dan to 6th Dan
6th Dan to 7th Dan
______ persons x RM270.00 = RM ___________
______ persons x RM320.00 = RM ___________
______ persons x RM370.00 = RM ___________
______ persons x RM420.00 = RM ___________

Total RM________________

Payment by Cash/Cheque: :__________________________________________

Received by :__________________________________________
Date :__________________________________________

__________________________________
Signature State’s Technical Chairman/
Head Instructor of Premier Clubs
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 TAEKWONDO MALAYSIA (WTF)
SENIOR UP-GRADING

DATE : 19TH DECEMBER 2022 (MONDAY)

TIME : 8.00 PM
VENUE : MULTI DYNAMIC MARTIAL ARTS GYM (MBW)
1, JALAN 53, PEKAN KEPONG ,52100 KUALA LUMPUR

1. Name …………………………………………………………………………………………….. MALE / FEMALE

2. NRIC No ………………………………… 3. Date of birth ………………………………….

4. Address …………………………………………………………………………………………………………………………..

…………………………………….……………………………………………………………………………………..............

5. Occupation …………………………………………………………………………………………………………………….

6. Tel No. (Res) ………………………………..(Off) …………………………….(H/P) …………...…………………..

7. Member organization (Club Name) ……………………………………………………………………………….

8. State or Premier Club Name : …………………………………………………………………………………………

8. TM Reg. BB No. …………………………………. 9. GAL No. ……………………………………………..……….

10. Present rank …..…………………..Dan/Poom

11. Date obtained present rank ……………………. 12. Rank applied for ….………….….Dan/Poom

13. Instructor’s name ………………………………………………………………………………………………………………….

14. Indicate the types of courses at National Level that you have attended. Kindly give the exact dates.

a) Referees Course
……………......................................................................................................................................
...................................................................................................................................................
……………......................................................................................................................................
……………......................................................................................................................................

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 b) Instructors Qualification Course
……………......................................................................................................................................
..................
……………......................................................................................................................................
..................
……………......................................................................................................................................
...............................................................................................................

c) Other Courses

……………......................................................................................................................................
..................
……………......................................................................................................................................
..................
……………......................................................................................................................................
..................
……………......................................................................................................................................
.............................................................................................

15. Are you a qualified referee? If yes, please state whether State, National or International.

…………………………………………………………………………………………………………………………………………………………..

16. Have you obtained the NSC National Accreditation Coaching Certificate?

Date obtained:…………………………………………….

17. Are you conducting any classes? Please state.

Place Day No of students

…………………………………….. ………………………. ………………

……………………………………. ………………………. ………………
……………………………………. ………………………. ………………

18. Do you hold any position in your State Association, whether administrative or technical? State
clearly
whether Secretary General, Treasurer, Chairman, Committee member, Chairman BBB, State Coach
etc.

……………………………………………………………………………………………………………………...
………………………………………………………………………………………………………………………

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19. I, the above applicant, hereby agree to indemnify the Taekwondo Malaysia (WTF) and its
Officials and my fellow members from any claim, loss or expenses as may arise in the event of any
injury, damage or death as may be suffered by me at such grading examination.

Date:___________________ ________________________________
(Applicant’s Signature)
20. FOR MEMBERS UNDER 18 YEARS OF AGE

I, _____________________________________________________________ I.C No.

_______________________
as parent / guardian, do hereby allow my son / daughter / ward to participate in the above grading
examination. I fully understand and agree with the above-mentioned conditions.

Date:___________________
________________________________
(Parent’s/Guardian’s Signature)
21. To be completed by the State Technical Chairman/Head Instructor
a) Discipline Poor / Average / Good / Excellent
b) Technical Poor / Average / Good / Excellent
c) Leadership quality Poor / Average / Good / Excellent

22. Recommendation of State Technical Chairman/Head Instructor

…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….

_____________________________________________
Signature of State Technical Chairman / Head Instructor

23. Application approved / rejected.

Date:______________________ ____________________________________
Chairman of Technical Executive Committee