ITA Black Belt Membership Application
On-Line Registration Form


International TaeKwon-Do Association
P.O. Box 281
Grand Blanc,   MI   48480   USA

This On-Line Registration Form
is for those who wish to pay by CREDIT CARD.


Complete the form below and then click "Submit Application" at the bottom of this page.

When we receive a copy of your current certificate of rank, we shall review it.
Once approved, we will then charge your credit card and process your application.

Please allow 4 to 6 weeks for processing.
(Payments are to be in U.S. Currency)

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Credit Card Holder Information

Name (As it appears on Card):
Street Address:
City:
State:
Zip Code:
Country:
Phone: (Required
E-Mail Address (Required)



Credit Card Information

Card Number:
    Credit Card:     Exp. Date: Month       Year:



Select Membership You Are Applying For




Membership Application Information

First Name:
Middle Initial:
Last Name:
Street Address:
City:
State:
Zip Code:
Country:
Phone: (Required)
    Date of Birth (Month):
    Date of Birth (Day):
Date of Birth (Year):
    Are You Teaching Tae Kwon Do?:
How Many Years Studying Tae Kwon Do?:
    Date of Rank (Month):
    Date of Rank (Day):
Date of Rank (Year):
Attach Your Certificate .jpg File:(Required):
 
    

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