LICENCE REGISTRATION Licence Registration Name* First Last DOB* Address* Street Address Address Line 2 City ZIP / Postal Code OccupationPhone*Grade*White - 1 stripe - 12th kyuWhite - 2 stripes - 11th kyuWhite - 3 stripes - 10th kyuOrange with white stripe - kari 9th kyuOrange - 9th kyuRed with white stripe - kari 8th kyuRed - 8th kyuYellow with white stripe - kari 7th kyuYellow - 7th KyuGreen with white stripe - kari 6th kyuGreen - 6th kyuPurple - 5th kyuPurple with white stripe - 4th kyuBrown - 3rd kyuBrown - 2nd kyuBrown - 1st kyuBlack - 1st danBlack - 2nd danBlack - 3rd danBlack - 4th danBlack - 5th danBlack - 6th danBlack - 7th danBlack - 8th danEmail* Enter Email Confirm Email Previous Licence Expiry DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Only for new Licence applicationsHave you ever practiced a martial art? Yes No If yes, please give brief details including affiliation, grade obtained & examinerHave you ever been convicted of a crime of violence? Yes No If yes, please give brief detailsDo you suffer a medical condition that could affect or prevent you practicing Karate? Yes No If yes, please give details including any regular medication.Upload Your PhotoI accept that training in karate could involve the risk of injury’* I accept I dont accept I also agree & acknowledge that my photograph may be taken during seminars and may be used by the Hombu Dojo & HDKI Ireland on Social Media or Brochures & related materials.* I agree I do Not agree We will never identify you without your prior consent.Select your club & Licence typeSelect a Club*HOMBU DOJO RANELAGHABBEYFEALE KARATE CLUBHARTSTOWN SHOTOKAN KARATE CLUBPALMERSTOWN SHOTOKANHombu Dojo New Licence / RenewalNew LicenceRenewalReplacement LicenceHARTSTOWN SKC New Licence / RenewalNew LicenceRenewalReplacement LicencePALMERSTOWN SHOTOKAN New Licence / RenewalNew LicenceRenewalReplacement LicenceABBEYFEALE KARATE CLUB New Licence / RenewalNew LicenceRenewalReplacement LicenceCAPTCHATotal 0,00 € Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name
