WFJ Dan application form (not for graduation)

A) Basic information
First name(*)
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Surname(*)
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Gender(*)
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Date of birth
A) Day (00)(*)
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B) Month (00)(*)
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C) Year (0000)(*)
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E-MAIL(*)
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Street address(*)
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State (fill if you use this)
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City(*)
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Postal code(*)
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Your country(*)
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B) MARTIAL ART INFORMATION
National organisation(*)
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Club(*)
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Teacher(*)
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Your current belt grade(*)
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(only numbers)

Reference
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Start date of martial arts(*)
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(day/month/year)

When you got the 1. Dan(*)
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(day/month/year)

Home page address
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Your picture(*)
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(like passport photo)

Write characters!(*)
Write characters!
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SUBMIT