Martial Arts Uniform/Belt Order Form


Letterhead - Color




First Name:     Last Name:  

SSN:     Date of Birth:  

Address Line 1:   

Address Line 2:   

City/Town: State: Zip Code:  

Primary Phone Number:     Cell Phone Number:      Work Phone Number: 

Best Time to Contact:     



Member’s First Name:  Member’s Last Name:

Date of Birth:

Height:  Feet  Inches

Weight:  Pounds


Please select your equipment and size.  If you are uncertain, please select the “Uncertain” selection in the size box, and we will give you the proper size.

Equipment Selection & Price:  Size:   

  • Upon ordering an Embroidered Black Belt, you will need to enter the member’s FULL NAME in the “Additional Comments” section of your checkout.
  • All equipment sales are for members of Dragon Yong-in Martial Arts, or for members who are in the process of registering for the programs of Dragon Yong-in Martial Arts.
  • ALL equipment orders are for in-store pickup only – no shipping.
  • If the location of your choosing does not have inventory in stock, your equipment will be ordered and shipped to that location.
  • There are no refunds for equipment purchases.
By signing below, I acknowledge that I fully understand the terms and agree to pay the full price of the equipment which I have selected.

Leave this empty:

Dragon Yong-in Martial Arts
Signature Certificate
Document name: Martial Arts Uniform/Belt Order Form
Unique Document ID: a235479381baf40109a38cb86862dbf9494da919
Timestamp Audit
2016-07-06 16:16:02 ESTMartial Arts Uniform/Belt Order Form Uploaded by Dragon Yong-in Sales - IP