WTKJ Individual Membership Form

Last Name:		First Name:	Date of Birth:
Address:			Apt #:
City:	State:	Zip:	Country:
Home Phone:		Work Phone:
Current Rank:		Last Promoted:
Former Experience (if any):

School Name:		School # / ID if applicable:
School Address:
Instructor Name:		Instructor Rank:
New Application: Renewal:
Membership		Application Fee:
Payment Method:
Credit Card #: Expiration:
Cardholder Signature:

When finished, print form out and mail with payment to: White Tiger Kenpo Jujits PO Box 805 Odessa FL 33556 FAX: 727-372-3354 note For Family Membership please have each member fill out the form and include all forms with the payment.

Shihan Jim Rathbone
6852 Westend Ave
New Port Richey FL 34655
727-372-2404 Phone #
Email: Shihan Jim Rathbone