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 are £10.00. This includes individual member insurance via FEKO ( Federation of English Karate Organisations)
Please see separate membership form.

Please make cheques payable to: KONJAKU SHIN LTD.
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.