JKI Membership Information Form

Jikishin-Kai International

Individual Membership Application
Applicant Category:
Name:

Prefix (Dr., Rev., etc.)First NameMiddle Name or InitialLast NameSuffix (Sr., Jr., PhD., etc.)
Street Address:

Street Address

Street Address Line 2

CityState / Province / County / Prefecture / Etc.

Postal / Zip CodeCountry
Mailing Address (if different):

Mailing Address

Mailing Address Line 2

CityState / Province / County / Prefecture / Etc.

Postal / Zip CodeCountry
Preferred Phone Number:

Country CodeArea CodePhone Number
Alternate Phone Number (if any):

Country CodeArea CodePhone Number
Email Address:
example@example.com
Date of Birth

MonthDayYear
Date
Gender:
Forms of Budo Currently Practiced:

Other (list below)
Other Forms of Budo Currently Practiced:
List here, separated by commas
Rank Currently Held in Shito-Ryu Karate-do
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Okinawa Kobujutsu
(Bo, sai, tonfa, kama, nunchaku, eku, etc.)
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Muso Jikiden Eishin-Ryu Iaijutsu:
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Shindo Muso-Ryu Jojutsu:
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Rank Currently Held in Ono-Ha Itto-Ryu Kenjutsu:
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Highest Rank Currently Held in a non-JKI Art:
Name of the Style of the Rank Listed Above:
(Kyokushin, Wado-Ryu, JKD, Judo, BJJ, etc.)
Name of Organisation Awarding the Rank Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Highest Awarded Budo Title Currently Held:
Name of Organisation Awarding the Title Listed Above:
Name of Organisation (enter "N/A" if no rank held)
Informal Title Used:
Other Informal Title Used:
Enter title above, if "Other" was selected from drop-down menu. Otherwise leave blank
Name of Your Current Dojo:
Dojo Name (if not currently training, enter "None" or "N/A")
Address of Your Current Dojo:

Street Address (if not currently training, enter "N/A" in all fields

Street Address Line 2

CityState / Province / County / Prefecture / Etc.

Postal / Zip CodeCountry
Phone Number of Your Current Dojo:

Country CodeArea CodePhone Number
Email Address of Your Current Dojo:
example@example.com
Name of Your Current Sensei:

First NameLast Name
What is Your Current Role at the Above Dojo?
Which of the Above Information Can We List on Our Membership Roster?
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Annual Individual Membership Dues
Individual membership dues for calendar year 2023

$25.00

Charter Membership Discount
25% discount for Charter Membership available only if annual dues are paid in full by 31 March 2023

$-5.00

Total

$0.00
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Jikishin-Kai International

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