USE BLOCK CAPITAL LETTERS ONLY

SURNAME Mr/Mrs/Ms/Mst/Miss .......................................................................................................................................................................

FIRST NAME ..................................................................................................................................................................................................

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  CLUB OR ASSOCIATION NAME.

NAME: .........................................................................................................................................................................................................................................................

CURRENT NUMBER OF STUDENTS ...............................................
 

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 will run for one year from date of joining).

Individual memberships for affiliated club members are £10.00. This includes individual member insurance via
FEKO (Federation of English Karate Organisations)
Please see separate membership form.

Payment can also be made by credit card or by bank transfer. Please call Konjaku Shin on 01472 267807 with your card details.

For BACS/SWIFT bank transfers, our account details are:

Bank: HSBC
Account Name: Konjaku Shin Limited
BIC: MIDLGB2112D
IBAN Number: GB60MIDL40222492210002

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.