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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:____________________________________