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Name/Family Name:_____________________________________________________
Address: ___________________________________________________________
__________________________________________________________________
Telephone: _______________________ Fax: ______________________
E-mail Address:______________________________________________
Date of birth: ____________________ Current Rank: _______________
Karate/Budo Style: ___________________________________________
Grade issued by: _________________ Certificate No: _______________
(Please include photocopy with this application) (Also attach 2 ID size pictures)
ORGANISATIONAL INFORMATION:
Name of dojo/ club: ___________________________________________________________
Address of dojo/ club: ___________________________________________________________
___________________________________________________________
Dojo Telephone No: ________________ Fax No: ___________________
E-mail Address: _____________________________________________
No. of Yudansha: ____ No. of Kyu Students: ___ Total No. of Students: ___
(If you have more than one dojo/club affiliated with you, complete the details above and attach a list of the names of the present instructors and the areas of all your affiliated dojo/clubs.
Please return to:
Ashihara Karate International Kaicho Hoosain Narker, P. O. Box 117, Retreat, 7965, South Africa Fax: +27 21 7011701 E-mail: info@ashiharakarate.org
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