KDA Lifetime Membership Application
Kuma Dojo Association Karate-Do International
Student or Instructor, lifetime membership fee - $5.00
Dojo lifetime membership fee - $25.00
MAIL APPLICATION(S) and MONEY ORDER TO: (make money orders 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:
Please list each date of Dan rank and add a copy of each dan certificate with application.
Shodan- Nidan- Sandan- Yondan- Godan- Rokudan- Nanadan- Hachidan-
Students, Please list each date of your 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 $5 Dojo - $25. BOTH $30.00
Signature:____________________________________
Print Name:____________________________________