?A?V?i?n

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.