GB Black Belt Diploma Application

1
What is your name?* This field is required.Please write your name as you want to be displayed on your diploma.
First Name
Last Name
2
What is your Gracie Barra Global ID?You can find your GB Global ID on your Foundations or ICP certificate.
3
What is your Gracie Barra school?* This field is required.Please list the GB school that you are a member of.
4
What is your email address?* This field is required.Please provide the email address you would like to receive the digital version of your diploma.
example@example.com
5
What is your phone number?* This field is required.Please provide the phone number we should reach you at. We may reach out to you via SMS or WhatsApp to gather more information. Make sure to include country code.
6
What is your mailing address?* This field is required.Please provide the mailing address you would like to receive your professionally printed diploma.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Date of your most recent belt promotion:* This field is required.Please provide the date you received your promotion for the diploma that you are applying for.
Date
Year
Month
Day
8
What rank are you applying for?* This field is required.Please provide the exact rank you are applying to receive the diploma.
Black Belt
Please Select
Black Belt
Black Belt First Degree
Black Belt Second Degree
Black Belt Third Degree
Black Belt Fourth Degree
Black Belt Firth Degree
Black Belt Sixth Degree
Red and Black Belt
Red and White Belt
Red Belt
9
What is the correct prefix of the instructor who promoted you?* This field is required.Please choose the correct option based on the rank of the Professor who promoted you. (Black Belt up to 6th degree are Professors, and Black Belt 7th degree and higher are Masters.)
Please Select
Please Select
Professor
Master
10
What is the name of the instructor who promoted you?* This field is required.Please provide the name of the Gracie Barra instructor who promoted you. This individual needs to verify your belt promotion and will be required to verify the accuracy of the information provided.
11
What is the email address of the instructor who promoted you?* This field is required.Please provide the email address of the Gracie Barra instructor who promoted you. This individual needs to verify your belt promotion and will be required to verify the accuracy of the information provided.
example@example.com
12
What is the phone number of the instructor who promoted you?* This field is required.Please provide the phone number of the Gracie Barra instructor who promoted you. This individual needs to verify your belt promotion and will be required to verify the accuracy of the information provided.
13
Please upload a copy of your driver's license or another form of identification.* This field is required.pdf or pic.
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Max. file size: 10.6MB
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14
Please upload a copy of your GB Foundations Certificate or GB ICP Certificate.* This field is required.Your ICP certificate must be valid and can not be expired.
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Max. file size: 10.6MB
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