Address: _________________________________________________________________________

___________________________________________________________________________________ 

Telephone: ________________________________ Fax: ____________________________________

E-mail Address:___________________________________________________________________

Date of birth: ______________________________ Current Rank: ___________________________

Martial Arts Style: _________________________________________________________________

Grade issued by: ___________________________ Certificate No: __________________________

(Please include photocopy with this application) (Also attach 2 ID size pictures)

ORGANISATIONAL INFORMATION:

Name of dojo/ club: ________________________________________________________________

Address of dojo/ club: ______________________________________________________________

__________________________________________________________________________________

Dojo Telephone No: _________________________ Fax No: ________________________________

E-mail Address: ____________________________________________________________________

No. of Black Belt: _________ No. of Kyu Students: __________ Total No. of Students: __________

(If you have more than one dojo/club affiliated with you, complete the details above and attach a list of the names of the present instructors and the areas of all your affiliated dojo/clubs.

Please return to:
ShinBudo Kai, P. O. Box 117, Retreat, 7965, South Africa 
Fax: +27 21 011701
E-mail:ashihara@iafrica.com