AMERICAN ISSHINRYU, INC.

(A New Jersey Non-Profit Corporation)

Membership Application

1. Name: ___________________________________________

2. What type of membership are you applying for?

( ) Dojo - $100 Yearly Dues

( ) American Isshinryu Dojo Student - $10 Yearly Dues (is associated with a Dojo that is part of American Isshinryu)

( ) Individual - $20 Yearly Dues (not associated with a Dojo that is part of American Isshinryu)

2a. If you are applying for Individual Membership, are you affiliated in any way with a dojo? ________. If yes, what is the name of the dojo? _______________________________.

3. Home Address: ___________________________________________

___________________________________________

Home Telephone Number: _____________________________

Cell Phone Number: ___________________________________

Email Address: ________________________________________

3a. Dojo Address: ___________________________________________

___________________________________________

Dojo Telephone Number: ______________________________

3b. If you are applying for Dojo membership, how many students does your dojo have?

Adult Students ________ Junior Students ________

Total dojo members including instructors ________

4. What type of martial arts do you study? _____________________________

5. How many years have you been studying martial arts? _______________

6. What is your current rank? _________________. Who awarded you this rank?

_________________________________________. Attach hereto a copy of your most recent rank certificate.

7. If you are applying for Dojo Membership, do you have insurance that covers your dojo and its members, instructors, students and/or guests? __________________. If yes, provide the name of your insurance company, policy number, policy period, limits of insurance and coverages provided. (American Isshinryu, Inc. requires that all dojos have appropriate insurance coverage)

______________________________________________________________

7a. If you are applying for Individual Membership, do you have insurance that covers you such as homeowners insurance, renters insurance or health insurance? __________________. If yes, provide the name of your insurance company, policy number, policy period, limits of insurance and coverages provided. (American Isshinryu, Inc. requires that all individuals have appropriate insurance coverage)

______________________________________________________________

8. Provide 3 references below which we can contact with regard to your possible membership to American Isshinryu, Inc.

Name	Telephone #	Years Known
	( )
	( )
	( )

9. Please describe below, in detail, what your expectations are of American Isshinryu, Inc.

I hereby certify that the information contained in this application is true and accurate to the best of my knowledge. I understand that any statements found to be willfully false may subject me to penalties.

BY: __________________________________ Date:

If the applicant is a minor, indicate the applicant’s age next to the their signature and have a parent or guardian sign below on their behalf.

BY: __________________________________ Date:

Parent/Guardian

For Administrative Use Only

Application Approved ( ) Registration # __________

Application Denied ( ) Reason for denial:_________________________

_______________________________________________________________________________

BY: __________________________________ Date:

Membership Information Submission:

Please submit your membership application and check (made out to “AMERICAN ISSHINRYU, INC.”) directly to Don Nash-8th Dan-Certification Chairman at:

Don Nash

611 Waterford Drive

Manchester, NJ 08759

or e-mail your questions directly to This e-mail address is being protected from spambots. You need JavaScript enabled to view it