Kuma Dojo Association Karate-Do International

Mudansha $5.00,Yudansha $10.00, Dojo- $50.00, Branch Chief $150.00

 MAIL APPLICATION(S) and MONEY ORDER TO: (make money orders out to John Farrell)

Kancho John Farrell; 1116 Largo Way; E. McKeesport, PA; 15035 USA

YOUR INFORMATION

FIRST NAME: MIDDLE INITIAL:                                                                  LAST NAME:

ADDRESS:

CITY: COUNTRY:

STATE: ZIP/POSTAL CODE:

PHONE: CELL: E-MAIL:

WEB SITE:                                                  DATE OF BIRTH:                                           DISCIPLINE:

Instructor's Please circle PRESENT Dan rank and add a copy of dan certificate with application.

Shodan- Nidan- Sandan- Yondan- Godan- Rokudan- Nanadan- Hachidan-

Students, Please circle present Kyu grade

9th kyu 8th kyu 7th kyu 6th kyu 5th kyu

4th kyu 3rd kyu 2nd kyu 1st kyu

DOJO INFORMATION:

DOJO NAME:                                                             CHIEF INSTRUCTOR:

ADDRESS:

CITY:

COUNTRY:

STATE: ZIP/POSTAL CODE:

DOJO PHONE; WEB SITE: E-MAIL:

CIRCLE ONE: Student-Kyu $5 Student-Dan $10 Dojo - $50.

Signature:_____________________________________ Date:______________

Print Name:____________________________________

 MAIL APPLICATION(S) and MONEY ORDER TO: (make money orders to John Farrell)

Kancho John Farrell; 1116 Largo Way; E. McKeesport, PA; 15035 USA