NAME:

REGISTRATION NUMBER:

MAILING ADDRESS:

CURRENT RANK:

DATE YOUR CURRENT RANK WAS AWARED:

NAME OF YOUR MARTIAL ARTS STYLE:

MARTIAL ARTS RANK THAT YOU ARE REGISTERING:

NAME OF STYLE YOU ARE REGISTERING:

NAME OF MARTIAL ARTS SCHOOL TO BE AFFILIATED:

ESTIMATED PHYSICAL TRAINING HOURS AT YOUR CURRENT RANK:

LISTED IN ONLINE REGISTRY:  YES / NO

YOUR SIGNATURE:                                                                                                   

MAIL TO:

John Frank Brado / Director, Chief Instructor / 2277 East Elm Street / Lima, OH 45804 / USA

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