JKI Membership Information Form

Jikishin-Kai International

Individual Membership Application
Applicant Category:*

Active (currently training in budo)Supporting/Sustaining (not actively training in budo)
Name: *

Prefix (Dr., Rev., etc.) First Name Middle Name or Initial Last Name Suffix (Sr., Jr., PhD., etc.)
Street Address:*

Street Address

Street Address Line 2

City State / Province / County / Prefecture / Etc.

Postal / Zip Code Country
Mailing Address (if different):

Mailing Address

Mailing Address Line 2

City State / Province / County / Prefecture / Etc.

Postal / Zip Code Country
Preferred Phone Number:*

Country Code Area Code Phone Number
Alternate Phone Number (if any):

Country Code Area Code Phone Number
Email Address:*
example@example.com
Date of Birth*

MonthDay Year
Date
Gender:*

MaleFemale
Forms of Budo Currently Practiced:*

Karate-doRyukyu / Okinawa KobudoIaido / Iaijutsu / Batto-ho / Batto-doJodo / JojutsuKenjutsu (Koryu)Kendo (Sport)AikidoJudoJujutsu / Aiki-jujutsuOther (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

City State / Province / County / Prefecture / Etc.

Postal / Zip Code Country
Phone Number of Your Current Dojo:

Country Code Area Code Phone Number
Email Address of Your Current Dojo:
example@example.com
Name of Your Current Sensei:*

First Name Last Name
What is Your Current Role at the Above Dojo?*
Which of the Above Information Can We List on Our Membership Roster?*

NONEMy NameMy Street AddressMy Mailing AddressMy Email AddressMy Personal Phone NumberMy Budo RankMy Awarded Budo TitleMy Informal TitleName of My Current DojoAddress of My Current DojoPhone Number of My Current DojoEmail Address of My Current DojoMy Role at My Current Dojo
My Products
prevnext( X )
Annual Individual Membership DuesIndividual membership dues for calendar year 2023
$25.00

Charter Membership Discount25% 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