United States Isshinryu Karate Association

Headquarters ~ 2202 Surfside Dr.

Anderson, SC 29625

(864) 225-8610

DOJO  and or INDIVIDUAL MEMBERSHIP APPLICATION FORM.
Please print, fill out, and mail to the address above.

Name_______________________________________________Phone_______________

Rank__________________________________Age______________Sex_____________

Home Address___________________________________________________________

City________________________________________ State________ Zip____________

Email Address___________________________________________________________

Name Of Dojo Affiliation____________________________________________________

Address____________________________________________Phone______________

City_______________________________State_______________Zip ______________

Name and Rank of Chief Instructor___________________________________________

________________________________________________________________________

ISSHINRYU KARATE HISTORY OF APPLICANT

Rank Date  Awarded by (Name & Address)

____________ __________ ______________________________________________

Rank Date Awarded by (Name & Address)

___________ __________ _______________________________________________

Rank Date Awarded by (Name & Address)

__________ __________ ________________________________________________

Rank Date Awarded by (Name & Address)

___________   __________   _____________________________________________

PERSONAL HISTORY AND DATA

Education, School, and College

Level___________________________________________________________________

Profession, other than

Karate__________________________________________________________________

Marital Status____________________________Number of Children________

Armed Forces Record________________________________________________________

LIST THREE REFERENCES (NAME, ADDRESS & PHONE - ISSHINRYU KARATE PRACTITIONERS)

1.______________________________________________________________________________________

2.______________________________________________________________________________________

3.______________________________________________________________________________________

I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THAT THE INFORMATION PROVIDED WITHIN THIS APPLICATION IS TRUE AND THAT I WILL UPHOLD THE RULES and REGULATIONS OF THE
"UNITED STATES ISSHINRYU KARATE ASSOCIATION". TM

SIGNATURE______________________

DATE_____________________

ATTACH THE FOLLOWING:

Check the circle below and send the fee attached to the application.

  "Chief Instructors" Dues $25.00 includes the Chief Instructors dues & Dojo Certificate

  "Black Belt Dues" $20.00 recent photo of applicant, (Black Belts only) Photostat of rank certificate (Black Belts only)

"Kyu Rank Dues" $10.00 fee for (under black belts.)

  $25.00 For U.S.I.K.A.  Black Belt Certificates
Kyu Rank Certificates are available for Dojo's if needed. $10.00 each

Mail all applications to association headquarters. See front page.

Make all (money orders or checks) payable to the U.S.I.K.A.

U.S.I.K.A. reserves the right to reject members at the Board of Directors discretion.

Any incomplete application will be returned to the applicant.

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