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Shito-Ryu USA Karate Do Kai - Membership

Contact Pacific Karate-do

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Shito-Ryu USA Karate Do Kai

MEMBERSHIP and RENEWAL FORM
                                                                                                                                   YEAR 2017

MEMBER # M-_____________

NAME: ______________________________________ AGE: _____________ D.O.B. _______________

ADDRESS: ___________________________________ CITY: __________________________________

STATE: _______________________________________ ZIP: ___________________________________

PHONE: ___________________________ Email: ____________________________________________

CURRENT RANK: __________________ DATE of ENROLLMENT: ____________________

(Return this form to: John Bartholomay)

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