Date _________________

  First Name _________ Last Name ____________________________

  Address  ___________________________________________

  City__________________________ State ___ Zip Code ____________

  Male __________  Female ____________ DOB ___/___/______

  Current Rank _____________ Phone Number: ________________

  E-Mail Address:  ________________________

  This application is for one of the following:

  Gup  Membership: $35 (3 Year application fee).

  Dan  Membership: first year $35. Renewable each additional year at a cost of $35.

  I am paying my Black Belt (Dan) Annual fee of $35 Due by January 15, of each  year.

  Black  Belt Testing fee $160.00 + ($35 Annual Dan Fee)

  This application may be faxed to the following number: 561-482-1896

  Credit Card  Number: __________________________________________ Exp. Date  ______________

  Are you enrolling in the Home Study Program _____ Yes _____ No

  If your answer is YES, what would be the best time to call you at home? __________________

  $35.00 N.A.T.S.D.F.

  $299.00 Home Study Program Annual Fee.

  Total  $_____________

  Make Checks  payable to North American Tang Soo Do Federation

  11435A Palmetto  Park Rd. Boca Raton, FL 33428

  For Information  call 561-482-9049

  Parents  Signature (if under 18 years of age)  _________________________________