Please print this form, fill out and send to the address below.

International Shuri-Ryu Association
2721 South Calhoun
Fort Wayne, IN 46807 U.S.A.
(260) 456-7788 FAX (260) 744-0824
E-Mail IntShuri@aol.com

NEW MEMBER INDIVIDUAL APPLICATION

Name:___________________________

Address:_________________________

State:________        Zip:____________

Phone:___________________________

Karate Rank:______________________

Instructor:_________________________

School:___________________________

City:____________________________
Age:______  Date of Birth _________________

City:_____________________________________

Country:_________________________________

Height:________Weight:________Sex:________

Time in Rank:_____________________________

Instructor's Rank:__________________________

Address:_________________________________

State:___________           Zip:_______________

Check One: Dan_____    Kyu_____

All black belts joining the International Shuri-Ryu Association, Inc., must attach a copy of current Shuri-Ryu rank certificatiion with the initial application fee.

Applications & promotions must have authorization from existing
International Shuri-Ryu Association Yudansha.

If the authorizing signatures are not obtained, the applixcation may be rejected by headquarters.

Application Fees: KYU DAN
New members $25.00 $55.00

INITIAL MEMBERS & PROMOTIONS RECEIVE NEW CERTIFICATEAND I.D CARD

_______________________
Applicant

_______________________
Shuri-Ryu Yudansha

_______________________
Date

_______________________
Date

Note: Promotions and Renewals are seperate transactions
Please use the appropraite form & fee for each.