Police Self Defense Institute: PSDI and/or Taiho Jujitsu Certification

Instructor Credentials - Taiho Jujitsu Certification

Rank Registration, Certification and Promotion Application
by Police Self Defense Institute
PSDI Website.

Use this form to register as a PSDI Instructor and For Taiho Jujitsu Rank through the PSDI.

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INFO:

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Registrant Fee:		$0.00
Group Fee:		$0.00
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Billing information

First Name

Last Name

Country

Address

City

State/Province

Zip/Postal

Phone

Billing and Payment
Billing and payment processing for Businesses' events is performed by Member Solutions, Inc. ("MSI"), and this contract is specifically assigned to MSI for all such purposes. Customer knowingly and irrevocably authorizes MSI to charge electronically Customer's bank account and/or credit card for any and all amounts due for Customer's, and anyone registering under Customer's, attendance and participation in the Event. Please note, you may see all or any portion of the following on your bank or credit card statement: "MSI*THEUSAKARATEFEDERATI 8882448044 ONLINE REG FEE". Any returned payment will be assessed a $25.00 fee. Any unsuccessful electronic transaction is subject to a $10.00 processing fee. MSI is not responsible for any bank fees incurred by Customer. MSI has the sole right to resubmit returned or declined items (plus applicable fees) without prior notice. BILLING INQUIRIES -- 888-244-8044 or by mail to PO Box 297, Hatboro, PA 19040.

Applicant Agreement
I represent that I am the person who appears on the application above. I acknowledge and agree to the statements, terms and conditions above, as well as any applicable terms and conditions for this registration, and that by typing my name below and completing this registration form, I am electronically signing the document, which will have the same legal effect as the execution of the document by a written signature and shall be valid evidence of my intent and agreement to be bound.

Applicant Signature
Please enter your full name in the space below.

Please click the button below to finalize your registration.

Registration inquiries:
Police Self Defense Institute
Office
psdi@psdi.us

or email USA Karate.

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Registrant

use this registrant for billing information

First Name

Last Name

Title

Address

Address (line 2)

City

State

Zip

Country

Home Phone

Mobile Phone

Gender

PSDI CERTIFICATION REQUESTED

If Taiho Rank Desired, select dan level.

Requested Effective Date of Credentials

For PSDI Instructor Certification

Date of Birth

Age

Agency Name/Contact

Agency Address

Agency email address

Occupation/Position

Highest Educational Degree

School/College where received

Email resume showing any and all

� � LawEnforcement Experience

� MartialArts Experience

� MilitaryExperience

� GovernmentExperience

� EducationalBackground and Experience

� PersonalBackground

to psdi@psdi.us.

For Taiho Jujitsu Certification

In addition to the above, please complete the below information.

Address of Where Currently Training

Instructor's Name and email address

Martial Art/Style

Current Rank

Date Received

For Dan Certification, please list each each Dan level, date received and person/organization giving the rank.

Please describe other Certifications received, date, and person/organization granting the credentials. For example, referee, first aid, ACMA, ASEP.

Name and Contact Information of Three References

Terms

Waiver and Release
I understand that the Police Self Defense Institute is a division of the USA Karate Federation and the statements below apply to both.

By voluntarily agreeing to these terms I, the undersigned, state I have read the below waiver and release, understand that I have given up for myself and/or my minor child substantial rights by agreeing to the terms and conditions.

In consideration of participating in any way in any USA Karate athletics/sports program, and related events and activities, and training, the undersigned:
1. Agrees that prior to participating, they will inspect the facilities and equipment to be used, and if they believe anything is unsafe, they will immediately advise their coach or supervisor or USA Karate personnel of such conditions) and refuse to participate.
2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence but the actions, inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time.
3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.
4. Release, waive, discharge and covenant not to sue The USA Karate Federation, its affiliated clubs, regional sports organizations, their respective administrators, directors, agents, consultants, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessees of premises used to conduct the event, all of which are hereinafter referred to as "releasees" from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury including death or damage to property, caused or alleged
to be caused in whole or in part by the negligence of the releasee or otherwise.

Personal Certification

Under penalty of expulsion from the PSDI, I hereby certify that the above facts are a true and accurate presentation of my background. I fully understand that I can be expelled and have any certification or recognition given to me withdrawn in the event of misrepresentation or fraud

Check this box to indicate that you have read and agree to all of the above terms & conditions

Delivery of Credentials

All PSDI Certifications are sent by PDF that will print 8.5 x 11 inches in excellent quality.

All Taiho Jujitsu credentials are sent by PDF that will print 11x17 inches in excellent quality. If you wish a copy printed and mailed, please check below and pay the additional cost.

Certificate Delivery

Optional Delivery by Mail (extra cost)

I acknowledge that I am applying for registration and/or certification the PSDI and that a full refund is not available because of costs incurred from this application.

By checking this box I accept these additional terms and conditions.

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