WTKJ School Membership Application

Owner's Information
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 Information
School Name:		Student Population:
School Address:
New Application: Renewal:
Club Membership Studio membership		Application Fee:
Payment Method:
Credit Card #: Expiration:
Cardholder Signature:

When finished, print form out and mail with payment to: WTKJ PO BOX 805 Odessa Fl 33556 Fax: 727-372-3354

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