PERSONAL INFORMATION
Email: （　　　　　　　　　　　　　　　　　　）	
Home Address: 
	Your  photograph

	Dojo:
	
Mobile: 	

Personal Data

Name	             			: 
Date of Birth                 	:  
Gender              		:  
Nationality       		:  
Occupation			: 
Experience  （Scale and place of your  Dojo , students, instructors,black belts and current state of activity）  	: 

Reason and purpose to do affiliate to WBKL　:

Hope to WBKL-Japan　:　

Your  Main  Karate Background –History

Black Belt Dan	Dojo	Year 	Master　name	

				

Main Participation to Karate Championship
Championship 	Year 	Place 	

			

※When you are Sihan, the description of the maximum result of the student whom you coached  is OK.
I hereby submit my Personal Information for your consideration for Membership.
Please attach the image for our understanding in appearance of your Dojo.
Description for supplementation (In case of being).