INSTRUCTOR CERTIFICATION APPLICATION

If you would prefer, download and fill out the application HERE

Name*

First Last

Gender*

Male
Female

Birth Date*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Present Rank Instructor Information

Instructor Name*

First Last

Instructor Rank*

School Name

School Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Do you presently own or operate a commercial school?*

YES
NO

Do You Work as An Instructor at a School Owned By Another Person?*

YES
NO

Forms Presently Taught

Kicho
Taegeuk
Palgwe
Kukkiwon Yudanja (Black Belt Poomsae)
Moo Duk Kwan
Pyung Ahn
ITF

Teaching Experience (Years/Hours)

USTA Membership#*

Present USTA Rank*

Rank Certification#*

Instructor Level Certification Desired*

Digital Agreement & Signature*

I certify the accuracy of the above information and agree to abide by the rules of the USTA.

Two Year Certification $150
Please make check payable to Chosun Taekwondo Academy and send to:

USTA c/o Chosun Taekwondo Academy
60 Galloway Road
P.O. Box 721
Warwick, NY 10990

Examiner’s Use Only

Applicant Recommended By

USTA Instructor Certification #

USTA Rank Certification #

School Name & Address (If different From Above)

Additional Comments

Examiner's Signature

Date

Instructor Certification Application

INSTRUCTOR CERTIFICATION APPLICATION

Present Rank Instructor Information

Examiner’s Use Only