25 Church Street Watertown MA 02472 USA 1-617-926-6986
APPLICATION FOR DAN PROMOTION DATE OF TEST: ___________________
Please print Mo/Day/Year
NAME______________________________________________________________________________________________________
Last First Initial
ADDRESS__________________________________________________________________________________________________
Street Address City State Zip Country
EMAIL ADDRESS (Please write clearly)_____________________________________________________________________________
DATE OF BIRTH_____________PLACE OF BIRTH_____________________________________________________SEX M__F__
Mo/Day/Year
OCCUPATION________________________________________________________CITIZEN OF____________________________
I began practicing HARI________________and presently hold the grade of_______________________________________________
Mo/Year
awarded to me ________________ by ____________________________________________________________________________
Mo/Year Examiner’s Name
at an examination held at ___________________________________________ I have practiced______________ since that grading.
Location Days/Hours
Branch_____________________________________________ I hereby apply for the grading of ____________ DAN
Instructor________________________________________________
I hereby commend this application to the consideration of the Examination Committee
__________________________________________ __________________________________________________
Instructor’s Signature Applicant’s Signature
TO BE COMPLETED BY APPLICANTS FOR NIDAN AND ABOVE
LIST PLACES AND DATES OF SEMINARS SINCE LAST EXAM
____________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________
____________________________________________________________________________________________________________
FOR HARI SOCIETY OFFICIAL USE
Promotion by Examination or Recommendation Disposition: Pass Fail
By _____________________________________ On __________________ At _____________________________
Examiner’s Signature Mo/Day/Year Location of Examination
Appoved by _____________________________________________________ Date ___________________________
HARI SOCIETY Examination Committee
Copyright 2006 CULIA KI CLINIC INC. All rights reserved