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American Chung Do Kwan, Ltd.
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Past Certificate Request Form
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Ship Certificates and/or Supplies to:
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Mailing Address:
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City / State / ZIP Code:
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Email Address:
scriptinphp@gmail.com
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Cell No:Work No:Home No:
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Instructor’s Name:
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Name of Taekwondo School/Club:
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Senior Testing Official:Donald J Trump, 9th Dan
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Location of Testing (if other than School/Club):
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For testing rank, use "9th gup,", "6th gup," "1st Dan," etc.
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STUDENT’S FULL NAME
FIRST M.I. LAST		TESTING
RANK		Date of Past Testing for which Certificate is Being Requested
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Joseph R Biden7th Dan01/20/2021
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 TOTAL AMOUNT ENCLOSED: $0.00
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PLEASE MAKE CHECK PAYABLE TO: American Chung Do Kwan, Ltd.
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PLEASE SEND ALL TESTING FEES IN THE FORM OF ONE CHECK TO:
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ACDKL | c/o Matthew Nagel | 26196 E. Pine St. | Calumet, MI 49913
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Please clear out the form once you have submited it to Master Nagel
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