Application Form

AMERICAN ISSHINRYU, INC.

(A New Jersey Non-Profit Corporation)

Membership Application

501 (c) (3) Tax Exempt # 26-4480597

Type of Membership (Check appropriate boxes)

$100 Yearly Dojo [  ] *comes with special benefits $35.00 for lifetime Member [  ]

New member [  ] Renewal [  ] Your ID #_________ Your Dojo #________

1. Name:________________________________________________________________

2. Address:_______________________________________________________________

3. City/State/Zip:___________________________________________________________

4. Telephone: ( ) _______________ Email:_________________________________

5. Dojo name:_______________________________ Instructor:______________________

6. Dojo address:____________________________________________________________

7. City/State/Zip:____________________________________________________________

8. Current rank:_____________________ Style:__________________________________

(Attach copy of most recent diploma)

9. Provide 3 references and telephone numbers: (For new members only)

___________________________ ______________________ ____________________

Phone:______________________ Phone:_________________ Phone:_______________

I hereby certify that the information contained in this application is true and accurate to the best of my knowledge. I understand that any false statements will lead to refusal of membership.

By:__________________________________________ Date:____________________

[ ] Check here if applicant is a minor, application must then be signed by parent/guardian.

Submit to:

American Isshinryu Inc.

c/o Shihan Don Nash

611 Waterford Dr.

Manchester, NJ 08759

******************************************************************************

For Administrative Use Only

Application Approved [ ] Registration # ______Dojo #________

Application Denied [ ] Reason:_____________________

By:___________________________________ Date:____________