International Uechi-Ryu Karate Federation
POB 217
Mount Dora, FL 32756
Tel: 321-273-0409 Fax: 352-653-3132
 Official Dantest Application Form
in effect after 4/4/2007 		Note: Your IUKF membership number is issued when you joined IUKF. If you are not a member, you may receive your membership kit from David Berndt. (dcberndt@aol.com)

PRINT CLEARLY! All information necessary for accurate registration of your rank.

Test date:__________Region:___________Test Fee Enclosed USD:__________
Full name: ____________________________________________________________
Birthdate: Month:_______
Day:______
 Year:_____
Black Belt Registration ID: _____________or your IUKF"membership" I.D._________________
Month&Year you began studying Uechi-Ryu: _____________Last Promotion Date: _______________

Spring Tests by June 1st; Fall Test: by Dec.1st.Late Application will be submitted with next Test.

Time-In-Grade authorization: As this candidate's Instructor,I certify that the candidate has accumulated
the following years and months time-in-grade towards the rank being tested for: Years:____ Months:____
and that this candidate has accumulated TOTAL active years training: _______
Attested to and signed by Instructor:_____________________________________________________
Signature of Applicant or Parent/Guardian:___________________________________________
Street:_____________________________City:_________________________________
State:_________Mailcode/Zip:_________Country:_______Tel:___________________
Fax:_______________E-mail:__________________________@________________

Testing Fee:$200 (non-members) $150 (Paid-up IUKF member)
Circle rank being tested for: 1 2 3 4 5 6 7 8 9 [IUKF Certificate Included]Retest Fee/$135 US
( Check if this is a retest______)Check here if test is for a Junior rank:_______)

Jr.Blackbelts:Pay$150.US test fee.Receive IUKF certificate.When qualified for adult rank, pays $150
and receives Adult Black Belt IUKF Certificate. For an embroidered belt visit the Uechi Store.
Result of Dantest:___________________Test Board Head:__________________________
Test Vote Data:____________________________________________________________________
Black Belt Registration Number Issued:_______________Date Registered:____________________