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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

 

PROMOTION CERTIFICATION FORM

Name:___________________________

Address:_________________________

State:________        Zip:____________

Karate Rank:______________________

Instructor:_________________________

School:___________________________

City:____________________________
Age:______            I.S.A. __________________

City:_____________________________________

Phone:___________________________________

Date of Promotion:_________________________

Instructor's Rank:__________________________

Address:_________________________________

State:___________           Zip:_______________

Check One: Dan_____    Kyu_____

Promotional Fees: KYU DAN
$25.00 $75.00

ALL PROMOTIONS RECEIVE NEW CERTIFICATE AND I.D CARD

ALL PROMOTIONS MUST HAVE PROPER AUTHORIZATION FROM EXISTING
INTERNATIONAL SHURI-RYU ASSOCIATION YUDANSHA

_______________________
Applicant

_______________________
Authorizing Yudansha

_______________________
Date

_______________________
Date

 

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