International Karate Organization Kyokushinkaikan (IKO)
OFFICIAL AFFILIATION APPLICATION FORM
(Please print this form)

Family Name:

Given name:

Address:

City:

Province (State):

Postal code:

Country:

Telephone No.: Country code:                           Area code:                           No.: 

Fax No.: Country code:                                      Area code:                           No.: 

E-mail Address: (if applicable)

Date of birth:

Grade: (Dan or Kyu)

Karate Style: (now training in/teaching)

Grade issued by:

Certificate No.:

(If grading certificate not issued by IKO, please include photocopy with this application)

OPTIONAL:

Name of dojo/ club:

Address of dojo/ club:

City:

State (Area):

Postal code:

Country:

E-mail Address: (if applicable)

Web page: (if applicable)

(If you have more than one dojo/club is affiliated with you complete the details above for the main dojo/club and attach list of the general area of all the dojo/clubs affiliated. 

Signature:                                                                         Date: 

Please return to:

International Karate Organization Kyokushinkaikan
International Liaison Office
Shihan John Taylor ( 8th Dan )
17 Marine Drive
 Waverlely, Australia 2024
Fax: 61-2-9369393     
E-mail: taylor@internet-australia.com
Homepage : http://homepages.tig.com.au/~stavros
 IN CANADA:
Shihan Roman Szyrajew (6th Dan)
272 70th Ave, Suite 102
Chomedey, Laval, Québec
Canada H7V 2P8
Tel/Fax (450) 682-3477
email: shihan@total.net
Homepage:  http://www.shihanroman.com		 IN THE UNITED STATES :
Shihan Tom Flynn (5th Dan)
e-mail: taflynn@ici.net