Website Membership Application
AMERICAN BUDOKAI INTERNATIONAL
PO Box 404, Bakersville, NC. 28705 wcmaa@aol.com
New Membership / Renewal / Promotion Application
PLEASE PRINT CLEARLY
DATE: ____________________ PHONE:______________________
NAME: ________________________________________________ DOB: ____/_____/_______
ADDRESS: _____________________________________________________________________
CITY: _______________________________ STATE: __________________ ZIP: _____________
AGE: __________ SEX: ___________ EMAIL ADDRESS:________________________________
SCHOOL: ______________________________________________________________________
INSTRUCTOR: __________________________________________________________________
STYLE: _________________________________ CURRENT RANK: _______________________
TIME IN MARTIAL ARTS:_______________ TIME IN CURRENT GRADE:__________________
TIME IN AMERICAN BUDOKAI INTERNATIONAL ____________________________________
PROMOTION RANK: ______________________________________________________________
PERSONAL REFERENCE:________________________________PHONE:___________________
_____NEW MEMBERSHIP (Include diploma, ABI uniform patch & I.D. card)--------$ 25.00
_____ ANNUAL RENEWAL MEMBERSHIP (includes diploma & I.D. card)----------$ 25.00
_____DAN GRADE PROMOTION & CERTIFICATE OF RANK-----------------------$150.00
_____CERTIFICATE OF TITLE-------------------------------------------------------------------$100.00
_____SCHOOL AFFILIATION CERTIFICATE-----------------------------------------------$ 75.00
_____KYU PROMOTION & CERTIFICATE OF RANK-----------------------------------$ 25.00
_____Additional ABI 3" Embroidered "Eagle & Sword" patch------------------------------$ 8.00
_____Shintoyoshinkai Rectangular Jiu Jitsu Sleeve Patch------------------------------------$ 8.00
Please remit payment via check or money order to:
American Budokai International
PO Box 404, Bakersville, NC. 28705
Date: _____________ Amount Paid:_____________
APPLICANT’S SIGNATURE: ___________________________________INSTRUCTOR’S SIGNATURE: _____________________________________________
Your membership packet, including certificate and patch will be mailed as soon as you application is received..