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

DOJO AFFILIATION FORM

Name of school:________________________________________________________________

Address:_________________________________________Phone:_______________________

City:_______________________________State:________________Zip:__________________

Owner:___________________________________________Phone:______________________

Instructor:___________________________           Instructor Rank:______________________

Time in Grade:____________________________ I.S.A.#______________________________

Owned by: Corporation________       Individual________

Total Number of Students:______ Dans:_____    Kyus:_____

OWNER/INSTRUCTOR MUST BE A CURRENT MEMBER OF
THE INTERNATIONAL SHURI-RYU ASSOCIATION

With your dojo affiliation you receive:

• Official certification of Affiliation.
• International Shuri-Ryu Association equipment at discount prices.
• International Shuri-Ryu Association patches at a discount price.
• Internet listing on the International Shuri-Ryu Association website.

ANNUAL DOJO AFFILIATION FEE

$100.00