KOKUSAI SENSHU TOKUKAI MEMBERSHIP FORM

 

PLEASE PRINT

 

FULL NAME_____________________________________________________________

                            SURNAME/LAST NAME            GIVEN NAME/FIRST NAME

 

 

DATE OF BIRTH_____________/____________/_____________

                                    DAY               MONTH                 YEAR

 

ADDRESS__________________________________________________________                                          

                                          STREET                                                     CITY               

                     

                      ___________________________________________________________

                        STATE                      POSTAL CODE                        COUNTRY

 

 

TELEPHONE:  HOME  (_____) ____________  E-MAIL_____________________

 

MEDICAL CONDITIONS ____________________________________________

 

OCCUPATION _____________________________________________________

 

PRESENT RANK ___________________________________________________

 

 

               

                DOJO NAME & ADDRESS _________________________________________

 

 

                INSTRUCTOR’S NAME ____________________________________________ 

 

                 I hereby certify the above information to be true.

 

DATE: _____________            

SIGNATURE __________________________________________

 

                                                        OFFICE USE ONLY                                           

 

COUNTRY OF ORIGIN ________________________________________________________________

PASSPORT # _________________________________________________________________________

DATE ISSUED________________________   EXPIRATION DATE ____________________________

RENEWAL ___________________________________________________________________________

RECORD OF RANK ___________________________________________________________________

INSTRUCTOR’S CLASS _______________________________________________________________

APPOINTMENTS _____________________________________________________________________

   

Mail all membership forms to:     Dr. Michael Steward Sr.

                                                        c/o KST Membership

                                                        4421 Hope Drive

                                                        Middletown, Ohio 45042