1. Name:______________________________________________________
   Address:___________________________________________________
   City:_______________________ State:________ Zip:_________
   Home Phone:_________________ Work:_____________ Ext:_____
   DOB:____________ Sex:______ Height:_________ Weight:____
   
2. Current Rank:_______________ System:______________________
   Dojo:______________________________________________________
   Address:___________________________________________________
   Sensei:__________________________ Sensei's Rank:___________

3. Please give us your Martial Arts Rank History:

4. I am seeking the following Certifications/Licenses:

___Annual Membership $25.00

___Kyu Grade Certification $25.00 per Kyu Grade

___Black Belt Certification ($50.00 per Rank Certificate)(includes Certificate & Listing in Budokaikan International's Black Belt Registry)

___School Charter $50.00 (includes Certificate & Listing in the Budokaikan International's Dojo Directory)

___Instructor Certification $50.00 (Lifetime)(Shidoshi & Sensei)

___Master Instructor Certification/License $75.00 (Lifetime)(Renshi, Shihan, Kyoshi, Hanshi)

___Budokaikan International World Sokeship Council (Soke, Soke Dai $100.00)(Sho Dai Sokeship $150.00 - must meet minimum requirements and submit required documentation)

___Certified Examiner License $50.00 (Must hold Black Belt Ranking)(includes Certificate & ID Card)

Please compleate all required information and return with payment to:

BKKI                                                  

c/o Sho Dai Soke D. E. Chase

P.O. Box 336

Bloomfield, New Jersey 07003-0336

Please make all checks and/or Money Orders payable to: DANIEL McGEE