Okinawa Karate-Do Muso-Kai gAssociate Membersh Application
(Please copy and fax or mail it. Please print)
I understand and agree with your organizationes purpose and rules and apply to be a member of my own free will.  

Signature________________________ Date(Month) _______  (Day) ________ (Year)_________

Name (First)_________________________________(Last)____________________________________
If you want to use a different name on the homepage

_______________________________________________________

Address: Country ______________________ Zip__________________________

    State/Province________________________________________________        
City/Town _________________________________________________

Street______________________________________________________

Phone#________________________ FAX_______________________

E-mail _______________________________________________________

Birth date  (Month)________(Day)________(Year)_________

Occupation/School____________________

Circle the information you want posted on our homepage

Last Name / First Name / Country / State / City / Town / Phone# / Email Address / Age

Annual Fee US$100         _____Pay Pal
           _____Check
Please make the check payable to Okinawa Karate-Do Center
Address:
Okinawa Karate-Do Center               Phone: USA801-262-1785
153E 4370S #15                      Fax:    USA801-262-1785
Murray Utah 84107
U. S. A.

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