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

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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

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RENEWAL APPLICATION

Name:___________________________

Address:_________________________

State:________        Zip:____________

Email:___________________________

Instructor:_________________________

School:___________________________

City:____________________________
Age:______               ISA #_________________

City:_____________________________________

Phone:(____)____________________________

Karate Rank:_____________________________

Instructor's Rank:__________________________

Address:_________________________________

State:___________           Zip:_______________

RENEWAL FEES:   KYU - $20.00     DAN - $20.00

___________________________
International Shuri-Ryu Member

_______________________
Date

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