THE ACADEMY OF SHOTOKAN KARATE 
Individual Licence Application and Registration Form

This form must be completed in full in BLOCK CAPITALS with the appropriate fee and SAE at correct
postal rates at least 110mm x 220mm all cheques payable to Academy of Shotokan Karate and sent to:

THE LICENCING OFFICER
ACADEMY OF SHOTOKAN KARATE
WHITE GATES
64 SEA LANE
EAST PRESTON
WEST SUSSEX
BN16 1ND

TITLE:………… SURNAME:………………………………….. FIRST NAME:………………………..….. DOB:……..……...........

ADDRESS:….………..….…..………...……………...…………………………………………………………………………………

………………………………………………………………. POST CODE:……………………………….. TEL:……......................

CURRENT GRADE:…………………… CLUB:………………………...……………. INSTRUCTOR:……….…….…….……...

PREVIOUS MEMBERSHIP No with A.S.K:…………...………….……………… EXPIRY DATE:……………………………......

Please do not enclose your record book with this application, allow at least 14 working days for return of licence


ANNUAL SUBSCRIPTION / INSURANCE - PLEASE HIGHLIGHT

NEW MEMBER (includes record book) £20.00

RENEWAL (no record book) £16.00

Under 8 years old (no record book) £10.00

YOU MUST ANSWER THESE QUESTIONS (Delete as applicable)
Are you STUDENT or INSTRUCTOR ?
Do you have separate instructors insurance YES NO
If yes please give the policy number and company name
Have you any health issues likely to impair activity (give full details overleaf) YES NO
Have you been convicted or charged with a serious crime (give full details overleaf) YES NO


IMPORTANT
YOU MUST ensure that your licence is valid AT ALL TIMES; you will NOT be allowed to take part in any A.S.K
training, grading or event without it - make a note of the expiry date NOW


DECLARATION TO BE COMPLETED BY THE APPLICANT
"I certify that to the best of my knowledge and belief the above details are correct. In the event of my
being accepted for membership, I accept the Articles of Association and by laws of the A.S.K together
with any amendments that may be made during my membership"


Signed:…………………………………………………….. (Parent or guardian if under 16yrs) Date:…….……….………..


Please note A.S.K will hold your membership details on computer