Executive Black Belt Training Application for Instruction

Due to the time required to complete your criminal background check, Executive Black Belt Training must receive your completed application with payment in full at least one month prior to your scheduled course start date. Executive Black Belt Training reserves the right to deny training to anyone for any reason. In the event that an application is not accepted, the course fee will be promptly refunded in full.

Applicant Information

Full Legal Name
Date of Birth Social Security Number
Current Address
City State
Occupation
Home Phone Work Phone
Person to Contact in event of Emergency
Phone Number
Emergency Contact Address
Name as You Wish it to Appear on Your Certification
Name as You Wish to be Addressed
Dobok (Uniform) Size (Consult M. Samane)
List most Recent Training Courses Attended with Dates of Attendance
   
   

Program Information

How often would you like to train with your assigned Instructor?
One Session per Month Two Sessions per Month

Indicate your Choice of Location for Training i.e. Your Own Location or Ours?
My location Executive Black Belt Training Facility

Credit card number
Expiration Date
Name as it Appears on Card

Background Check

Executive Black Belt Training requires a background check as part of your application process. A non-refundable $75 processing fee, payable to Master Samane’s Karate Institute, will apply to this service. Please provide a credit card number to allow Executive Black Belt Training to process your application.
Credit card number
Expiration Date
Name as it Appears on Card

Statement of No Criminal Record, Mental Illness or Substance Abuse
By my signature on this application, I state that I have no criminal convictions, am not currently under indictment or prosecution for any offense, and am not wanted for questioning or arrest by any law enforcement or government agency. I further state that I have no history of mental illness or substance abuse. I understand that my training may be terminated at any time during the course I my actions are not deemed appropriate by Executive Black Belt Training’s staff. I agree to sign a document releasing Executive Black Belt Training from any liability that may occur during the course of training or thereafter. I understand that my tuition is non-refundable without 90 days advance notice of cancellation.
Applicant’s Signature Date

Character Witness Statement

The following character witness statement must be completed and signed by a respected member of the applicant’s community, who has known the applicant for at least five years and who is not a member of the applicant’s immediate family.

I certify that I have known for at least five years and can attest to the good, moral character of the applicant. I have no knowledge of any criminal activity, mental illness or substance abuse by the applicant. I recommend applicant for training without hesitation or reservation.
Character Witness Signature Date of Birth
Current Address
City State Zip
Occupation
Work Phone Home Phone