Affiliation Application Form Application Type New Affiliation Renewal Name Address City Agastinuagan Anandpur Anjira Anugul (Angul) Arjyapalli Asika Athagad Athmallik Badagada Badakodanda Badamba (Nizigarh) Badmal Balagoda (Bolani) Balangir Baleshwar (Balasore) Baliguda Balimela Balipatapur Balugaon Banaigarh Banapur Bandhbahal Bangomunda Banki Barapali Barbil Bardol Bargarh Baripada Basudebpur Baudhgarh (Boudh) Belagachhia Bellaguntha (Belaguntha) Belpahar Bhabinipur Bhadrak Bhakarsahi Bhanjanagar Bhapur Bhatli Bhawanipatna Bhuban Bhubaneswar Bijepur Binika Biramitrapur Birapratappur Bishamakatak (Bissam Cuttack) Borigam Boriguma (Borigumma) Brahmabarada Brahmapur (Berhampur) Brajarajnagar Budhapanka Buguda Bundia Burla Byasanagar Champua Chandapur Chandili Charibatia Chhatrapur Chikiti Chitrakonda Choudwar Cuttack Dadhapatna Daitari Damanjodi Danara Daringbadi Debagarh Dera Colliery Township Dhamanagar Dhenkanal Digapahandi Dungamal Erei Fertilizer Corporation of India Township (F.C.I. Township) Ganjam Ghantapada Godiputamatiapara Golabandha Gopalpur Gotamara Gudari G. Udayagiri Gunupur Hatibandha Hinjilicut Hirakud Indipur Itamati Jagatsinghapur (Jagatsinghpur) Jajanga Jajapur (Jajpur) Jalda Jaleshwar (Jaleswar) Jashipur Jatani Jeypur (Jeypore) Jharsuguda Jhumpura Joda Jorada (Bada) Junagarh Kabatabandha Kabisurjyanagar (Kabisuryanagar) Kaipadar Kalarangiata Kaliapani Kalyanasingpur Kamakshyanagar Kandasar Kanheipur Kantabanji (Kantabanjhi) Kantilo Karanjia Kashinagar Kendrapara Kendujhar Kesinga Khaliapali Khalikote (Khallikote) Khandapada Khariar Khariar Road Khatiguda Khordha Kochinda (Kuchinda) Kodala Koida Konark Koraput Kotpad Krushnanandapur Kuanrmunda Kukudakhandi Kulad Kullada Kunjabangarh Kurumuli Lalsingi Lathikata Lochapada Loisinga Madanpur Rampur Majhihara Makundapur Malkangiri Mohana Mukhiguda Mundamarai Nabarangapur (Nabarangpur) Nalco Nayagarh Nilagiri Nimapada Nuahata Nuapatna O.C.L. Industrial Township Odagaon Padmapur Palalahada Palurgada Panposh Papadahandi Paradip Paradipgarh Paralakhemundi Pathar Patnagarh Patrapur Pattamundai Phulabani (Phulbani) Pipili Pitala Polasara Pratapsasan Puri Purusottampur Raighar Rairangpur Rajagangapur (Rajgangpur) Rajasunakhala Rambha Ramgarh Ranapurgada Raurkela (Rourkela) Raurkela Industrial Township Rayagada Rayagada Redhakhol (Rairakhol) Remuna Rengali Rengali Dam Project Township R. Udayagiri Sambalpur Saranga Sayadpur Sheragada Sohela Sonapur (Subarnapur, Sonepur) Soro Subalaya Sunabeda Sundargarh (Sundergarh) Surada Surala Suvani Talcher Talcher Thermal Power Station Township (T.T.P.S. Township) Tangi Tarbha Tensa Tikarpada Tipo Titlagarh Tushura Udala Umarkote (Umerkote) Venkatraipur Pin Code Phone Number Email Website (if any) Head Instructor Name Qwan Ki Do Rank / Belt of Instructor Instructor Certification Number (if applicable) Years of Teaching Experience Additional Qualifications Dojo / Hall Size (in Sqft) Training Days Sunday Monday Tuesday Wednesday Thursday Friday Saturday Timing 5.00 Am - 7.00 Am 6.00 Am - 8.00 Am 7.00 Am - 9.00 Am 8.00 Am - 10.00 Am 9.00 Am - 11.00 Am 10.00 Am - 12.00 Pm 11.00 Am - 1.00 Pm 12.00 Pm - 2.00 Pm 12.00 Pm - 2.00 Pm 1.00 Pm - 3.00 Pm 2.00 Pm - 4.00 Pm 3.00 Pm - 5.00 Pm 4.00 Pm - 6.00 Pm 5.00 Pm - 7.00 Pm 6.00 Pm - 8.00 Pm 7.00 Pm - 9.00 Pm Number of Students Currently Enrolled: Available Equipment & Safety Gear Yes No Affiliation Requirements Copy of Head Instructor’s Martial Arts Certificates ☐ Institute Registration Certificate / Proof of Establishment ☐ 2 Passport Size Photos of Head Instructor ☐ Proof of Address of Institute / Club ☐ Affiliation Fee Payment Receipt Acceptance I hereby declare that the information provided above is true and accurate to the best of my knowledge. I agree to follow the rules, guidelines, and code of conduct of the Qwan Ki Do Association and understand that failure to comply may result in suspension or termination of my affiliation. Submit
