Dojo/Organization:_______________________________________________________________
Sensei:_________________________________________Rank:___________________________
Address:________________________________________________________________________
Zip:___________________
Last Date Promoted:______________
Name on Certificate:_________________________________________
Present Rank:________________________________________
Promotion Date:_____________ SKKF No# ________________
Kobudo Rank:____________________ No# _________________
Karate Rank:____________________ No# _________________
Complete this form CAREFULLY and LEGIBLY. Mail with a U.S. Money Order, for the full amount of Membership and Rank Certificate which is combined into one to the above address in the name of Tyrone Wiggins
. Do not send cash. Request will be handled promptly upon arrival. For individuals to receive a promotional certificate from
Date:___________________ Total Fees:______________