LICENCE REGISTRATION Licence Registration Name* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City ZIP / Postal Code Email* Enter Email Confirm Email Occupation Phone*Grade*White Belt / BeginnerWhite - 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 danPrevious Licence Expiry DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Only for New Applicants:Have 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 photographAccepted file types: jpg, png, jpeg, Max. file size: 8 MB.This should be a passport type photo which will appear on your licenceAll Registrations:I accept that training in karate could involve the risk of injury’* I accept I don't 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 a Club*ABBEYFEALE KARATE CLUBEalaín Karate Dojo - SligoHARTSTOWN SHOTOKAN KARATE CLUBH.S.K. BallaghaderreenPALMERSTOWN SHOTOKANHOMBU DOJO RANELAGHHombu Dojo New Licence / RenewalNew LicenceRenewalReplacement LicenceFor HOMBU DOJO CLUB membersHARTSTOWN SKC New Licence / RenewalNew LicenceRenewalReplacement LicenceRenewal And ReplacementPALMERSTOWN SHOTOKAN New Licence / RenewalNew LicenceRenewalReplacement LicenceRenewal and ReplacementABBEYFEALE KARATE CLUB New Licence / RenewalNew LicenceRenewalReplacement LicenceEalaín Karate Dojo New Licence / RenewalNew LicenceRenewalReplacement LicenceRenewal and ReplacementH.S.K. Ballaghaderreen New Licence / RenewalNew LicenceRenewalReplacement LicenceRenewal and ReplacementRenewal Arrears / Extra Yearsno arrears/extra1 year arrears/extra2 years arrears/extra3 years arrears/extraTotal Credit CardCard Details Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.
