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APPLICATION FOR MEMBERSHIP

Membership Fees____ Individual Lifetime = $100

Date: __________

Name: ________________________________________ Date of Birth: ___________________

Address: ______________________________________________________________________

City/State/Zip: _________________________________________________________________

Home Phone: ____________________________ Work Phone: __________________________

E-mail Address: ________________________________________________________________

Name of School: _________________________________ Date School was Established: _____

Current Instructor: _________________________________ Phone: _______________________

School Address: _______________________________________________________________

Current Rank: ________ Date Given: _________ Promoted by: _________________________

Date of 1st degree, Kajukenbo: ________________ Promoted by: _________________________

Tell us about you and why you want to join the KAA?

Please send completed Application for Membership and Membership Fees to:

KAA - Gaylord's Method

P.O. Box 580488

Elk Grove, CA 95758