Registration Form HDKI Ireland Licence Registration for members of Hombu Dojo Karate Club. For members of other HDKI clubs please go to HDKIIRELAND.ORG to register your licence (e.g. Hartstown, Palmerstown). "*" indicates required fields Name* First Last If you are completing this form for a minor (under 18) please answer all questions For Them except the phone number and email address which should be that of their parent/guardian.Date of Birth* DD slash MM slash YYYY Address* Street Address Address Line 2 City ZIP / Postal Code Occupation Phone*Grade*White beltWhite- 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 Are you registering a new licence?* Yes No, I'm renewing my licence I've lost my licence Previous Licence Expiry DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Licence/Member Number Only for new Licence applications(Only for new applications) 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 photoAccepted file types: jpg, png, Max. file size: 3 MB.jpg or png files accepted, only for new licences (optional) - Max File size 3MB!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 Karate International on Social Media. I agree We will never identify you without your prior agreement.Licence TypeHombu Dojo New Licence / RenewalNew LicenceRenewalReplacement LicenceMultiple Years or Arrearsnone+ one year+ two years+ three years+ four years+ five years+ six yearsIf you would like to pay multiple years or your licence has expired for more than one yearTotal Pay by Card*Card Details Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.