Directions: The information requested in this application must be typed or printed clearly. Any illegible information will cause this application to be returned to you and will delat the process in recognizing your rank and issuing your certification(s). This application must be filled out completely and returned with appropriate fees. Any missing information, fees or invalid information will also cause this application to be returned to you. This application must be mailed to the National Headquarters NJJF P.O. Box 336 Bloomfield, NJ 07003. All Money Orders are to be made payable to: D. E. Chase
Name: _________________________________ DOB: ______________
Age: ______ Sex: _________ Height: __________ Weight: _________
Address: ___________________________________________________
Home Phone: ____________________ Work Phone: ________________
Dojo: ______________________________________________________
Address: ___________________________________________________
Sensei: ____________________________ Dan Rank: _______________
Ryu/Style: ___________________________________________________
Current Ranking: ___________________ Rank Date: _______________
Please provide photo copies of all Kyu/Dan grades you wish to have certified.
CERTIFICATION REQUEST:
___ Annual Membership Fee ($35.00)
___ Lifetime Membership Fee ($125.00)
___ Kyu Grade Certification Fee ($25.00 each)
___ Black Belt Certification Fee ($100.00 per Certification)
___ Affiliate School Charter Fee ($50.00)(Lifetime Registration)
Name of Dojo: ___________________________________________________________
Address: ______________________________________________________________
System/Ryu: ___________________________________________________________
___ Instructor Certification Fee ($50.00)(Lifetime Registration)
Please Indicate: ( ) Shidoshi - 1st Dan thru 3rd Dan ( ) Sensei - 3rd Dan or higher
___Master Instructor Certification Fee ($250.00)(Lifetime Registration)
( ) Renshi - 5th Dan ( ) Shihan - 6th Dan ( ) Kyoshi - 7th Dan ( ) Hanchi - 8th Dan or higher
___ Sokeship Recognition ($350.00)(LifetimeRegistration)
Please Indicate: ( ) Soke - 5th Dan or higher ( ) Soke Dai - 9th Dan or higher ( ) Sho Dai Soke - ($500.00 Review & Recognition Fee) Special Requirements apply. Contact National HQ for details.
I, __________________________________________, hereby make application for Membership/Rank Certification in the National Ju Jitsu Federation and certify that all information contained herein is true and accurate to the best of my knowledge. I understand that I must renew all annual memberships, charters and/or certifications that I may receive. I agree to conduct my school/club/Dojo in accordance to the rules and regulations of the National Ju Jitsu Federation.
_____________________________ ___________________
Signature Date
