Name		D.O.B.
(Name as it is to appear on your Membership Certificate)		(Use Format: MM/DD/YY)
Address 1
Address 2
City		State
Zip Code		Country
Phone (with area code)		E-mail Addr
Martial Art Style/System
Current Rank		Title
By checking this box, and submitting this application for membership, I, the applicant, indicate that I have read, fully understand, and agree to all the terms and conditions of membership. I also understand that if I do not keep my membership current and in good standing, my membership will be terminated by Olohe Solomon Kaihewalu.