THE SHOTOKAN KARATEDO OF JAPAN

FEDERATION LIFETIME AFFILIATION

MEMBERSHIP APPLICATION

Please print this page and  read all sections carefully and fill in all pertinent information where required.  This application may be used for either the SCHOOL/CLUB affiliation or the YUDANSHA membership.  For easier processing, please prepare as much of the application as possible.  If a section does not apply to you, please "N/A" the non-applicable space, or draw a line through the entire section if it does not pertain to your membership needs.                        

PLEASE PRINT OR TYPE

SCHOOL/CLUB AFFILIATION____________________________

INDIVIDUAL/YUDANSHA________________________________

                                                     (includes Chief Instructor)

COMPLETE ALL SECTIONS IF APPLICANT IS CHIEF INSTRUCTOR

NAME:_____________________________________MALE_________FEMALE_________

                                                DOB:_________________AGE:_________HEIGHT:____________WEIGHT:___________

STREET: _______________________________________________APT #:_____________

                                                CITY:_________________STATE:________ZIP:____________COUNTRY:____________

TELEPHONE: (     )___________________(HOME)_____________________(E-MAIL)

OCCUPATION/EMPLOYER:__________________________________________________

                                                DOJO/SCHOOL/CLUB:______________________________________________________

CHIEF INSTRUCTOR:_________________________________ RANK/DAN:___________ 

SHOTOKAN RYU or    ASSOCIATION:_________________________________________

CLUB ADDRESS:___________________________________________________________

                                                CITY:_________________STATE:________ZIP:____________COUNTRY:____________

DOJO PHONE: (     )_______________________TOTAL YEARS EXISTING:____________

TOTAL YEARS KARATE STUDY:___________  YEARS OF SHOTOKAN___________

PRESENT KYU/DAN RANK:________________ YEAR RECEIVED:___________________

CERTIFICATION GRANTED BY:______________________________________________

                                                                                                                 (ORGANIZATION/AUTHORIZED PERSON)

SIGNATURE:________________________________________ DATE:_________________     

LIFETIME REGISTRATION FEE

SCHOOL/CLUB:-------$100.00                             YUDANSHA:-------$25.00

  Include all application fees and photocopy (color) of current certificate for processing.  Send all materials to:

SKJF

P.O. BOX 1843

PINELLAS PARK,  FL.  33780-1843