USE BLOCK CAPITAL LETTERS ONLY

SURNAME Mr/Mrs/Ms/Mst/Miss _______________________________________________________________________________________

FIRST NAME(S) _____________________________________________________________________________________________________

ADDRESS __________________________________________________________________________________________________________

POST CODE ______________________ TELEPHONE ___________________________GRADE ___________________________________

POSITION IN CLUB/ASSOCIATION ____________________________________________________________________________________

PRESENT GRADE AWARDED BY (examiner) ____________________________________________________________________________

PREVIOUS ASSOCIATION (if any) _____________________________________________________________________________________

DATE OF BIRTH _______/________/____________  E-mail Address __________________________________________________________

CLUB NAME (Name you would like to appear on the Affiliation Certificate)
PLEASE NOTE: AFFILIATIONS WILL NOT BE ISSUED IN A COUNTRY'S NAME; ONLY A CLUB OR ASSOCIATION.

NAME:______________________________________________________________________________________________________________

CURRENT NUMBER OF STUDENTS _____________________

All club members and instructors must also take out individual membership and insurance with Konjaku Shin at a cost of £12.50 per member.
 

IMPORTANT: DAN GRADES WILL NOT BE AUTOMATICALLY TRANSFERRED. INSTRUCTORS WISHING TO HAVE THEIR DAN GRADES RECOGNISED MUST TRAIN WITH, AND BE BE ASSESSED BY SENSEI DAVE KERSHAW.

I wish to affiliate the above club(s) to the Konjaku Shin National School of Karate, and enclose the annual affiliation fee of £GB 30.00.
(affiliation is for the current year, and runs from January 1st to December 31st
Please make cheques payable to: KONJAKU SHIN.
Payment can also be made by credit card. Please call Konjaku Shin on 01472 267807 with your card details.

Signed ______________________________________ Date _______________

Please send this form and affiliation fee to: Mr D. Kershaw.  Konjaku Shin National School of Karate,
Lower Spring Street, Grimsby, Lincolnshire DN31 3JS, England.