AFJ MEMBER APPLICATION PRINTABLE FORM

To receive your AFJ Certificate (with a blue and red yin-yang), print this form

page, fill it out and send it with your $40 Instructor Registration fee to:

American Federation of Jujitsu®
1225 Felmey Road
Winfield, PA 17889 USA

Name ____________________________________________________________

*Requested Rank __________________________________________________

(*Standard AFJ format example: Nidan, 2nd Degree Black Belt.)

**Style:__________________________________________________________

(**As you would like to appear on your certificate, be sure and double check for spelling and capitalizations. (not all capital letters)

NOTE: ONLY ONE STYLE PER APPLICATION

Number of years after you’ve received your First Degree Black Belt

Are you the Founder of this system? . YES . NO ___________________________

If your are the founder, please include your system’s belt requirements

Mailing Address ____________________________________________________

_________________________________________________________________

_________________________________________________________________

Email Address______________________________________________________

Date of Birth_______________________________________________________

School Name (optional) ______________________________________________

Your web site (optional) _____________________________________________

Please write brief outline of your Martial Arts experience or send a copy of your rank certificate.