GRADING: NEW BELT: OTHERS: TOTAL :

RM RM RM
BLACK BELT GRADING RM
KELAB DARUL EHSAN, AMPANG
1 DECEMBER 2023 @ 8.00 am CURRENT GRADE Please attach the following :
pls tick ( √ ) Latest 2 passport size photos (write name on the
1st Grade back of photographs & DO NOT staple)

1st Dan/Poom Photocopy of IC/MYKID

Closing date : 17/11/2023 Photocopy of current Dan/Poom/1st Grade Certificate
2nd Dan/Poom

Photocopy of 2023 TM BB Membership card (for 1st

Full Name as per IC/MYKID Black/Poom above)
(in capital letters) .

IC/MYKID No: Date of Birth:

Gender: Contact No:

Please submit photocopy IC
TM Reg BB No: Present Poom/Dan:

Address:

Date Obtained Present Poom/Dan Apply for:

Poom/Dan:
Instructor’s Name: Training Centre

I am aware of the possibility of my son/daughter/ward being injured during the Black Belt Grading and I hereby undertake and
agree to that I will not attach any blame or bring civil proceedings against KORYO TAEKWONDO CLUB, INSTRUCTORS, SCHOOL
AND MY FELLOW MEMBERS.

____________________________ _______________________
Applicant’s Signature Date

FOR MEMBER UNDER 18 YEARS OF AGE

I, ________________________________________________________________ NRIC 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.

___________________________ _______________________
Parent’s /Guardian’s Signature Date

NOTE: 1st Poom/Dan & above must be a registered TM Black Belt for the year 2023. Ensure the age and the time limit criteria
for Dan Promotion are sufficiently before applying. Closing date for submission before or by 17/11/2023
................................................................................................................................................. ..............................................

Payment Receipt
Grading Date : 1 DECEMBER 2023 @ KELAB DARUL EHSAN, AMPANG

1st Grade to 1st Poom/Dan

Received from
1st Poom/Dan to 2nd Poom/Dan
the sum of RM being the payment of grading fee. 2nd Poom/Dan to 3rd Poom/Dan
Others
_____________________
Received by: Date :
 Taekwondo Malaysia (WTF)
BLACK BELT/POOM PROFILE & REGISTRATION FORM
(Kindly print clearly when filling up the form)

REGISTER NO. TM

APPLICATION FORM FOR REGISTRATION OF:

1. NEW BLACK BELT 2. NEW POOM

FOR THE YEAR 2 0 2 3

I hereby apply for my registration as a Black Belt / Poom and agree

to abide by the Constitution and Rules and Regulations of the Taekwondo Malaysia ( WTF ).

Full Name:
(Tick) D D M M Y E A R
NRIC/B.CERT Sex M F Date of Birth:

Occupation:

Address:

Pos Code: City State

Tel: Fax

Name of State
/ Club : K O R Y O T A E K W O N D O C L U B

Dan Reg.No(Previous) Kukkiwon No

Poom T M

Payment: RM Email

I, the above named, hereby accept the TM Constitution and By-laws and apply to be registered with the Taekwondo
Malaysia (TM/WTF) and I declare that the information given above are true and current to best of my knowledge.

Signature of parent/Guardians Signature of Applicant

Full Name :

I.C No.:

Date:

(OFFICIAL USE ONLY)

The above application for registration as (a) Black Belt is APPROVED REJECTED
(b) Poom is APPROVED REJECTED