2012 - U.S. Open LasVegas / Poomsae Seminar

Kukkiwon/WTF Poomsae Seminar

Las Vegas, NV

February 20121

1:00 - 5:00 p.m.

Location: TBA

Instructor: Grandmaster Soon Pil Hong – Certified by WTF (IR)

All participants will receive credit toward USAT-MAC Poomsae Instructor Certification

Black Belt participants are eligible to apply for

USAT-MAC National Dan Rank Certification Test.

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Online registrations must completed by __

to avoid late fee ($10.00)

Full Name

First NameLast Name

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Best Phone

Area CodePhone Number

E-mail

Kukkiwon Dan

Date Kukkiwon Dan Issued (If NA please enter "Jan. 1, 1920")

MonthDayYear

Kukkiwon Dan # or NA

USAT-MAC Dan

USAT-MAC Dan # or NA

Date USAT-MAC Dan Issued (If NA please enter "Jan. 1, 1920")

MonthDayYear

Dan Rank Issued by Other Organization

Name of Organization or NA)

Organization's Dan # or NA

Name of your School/Club

Instructor's Name

Instructor's Rank

School/Club Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Club Phone Number

Area CodePhone Number

Club E-mail or "NA@na.com"

Club Web Address or "www.na.com"

Your Position at Your School (Check all that apply)

School/Club USAT # (or NA)

Your USAT # (or NA)

Purchases & Payment

Choose All that Apply

Sport Poomsae Seminar (USAT Member) - 4 Credit Hours ($60 Now - $80 after 5/5)$80.00

Sport Poomsae Seminar (Non-USAT Member) - 4 Credit Hours ($80 Now - $100 after 5/5)$100.00

USAT-MAC Official Uniform + Patch + Embroidered Belt ($79.00 + $12.00 S&H)$91.00

Dinner - Fri. 5/11$25.00

Dinner - Sat. 5/12$25.00

Total $0.00

If you ordered a USAT-MAC Official Uniform and Belt, please provide the following information:

Uniform Size

Belt Size

Normal delivery time is 4 - 6 weeks.

Name on Credit Card used for this purchase. (Helps match purchaser with participant.)

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