Okinawa Uechi-ryu Family of Organizations (C)
POB 217
Mount Dora, FL 32756

Tel: 321-273-0409 Fax: 352-653-3132
Application form: for Affiliated Organizations

This form to be faxed or mailed.

Members receive password to private "learning Center" website, monthly e-mail video clip instruction tips, Reduced priced rank certificates, as earned, from the IUKF, reduced rates at IUKF activities, Book, Video and product discounts.
Organizations  receive distributor's discounts on all products and activities

Affiliation: ( ) Uechi-ryu  ( ) Shoheiryu ( ) Other _________________________________________________

Name of Organization:______________________________________________________________________

Address: __________________________________________________________________________________

City: ______________________________State__________________________Postal Code______________

Country___________________________________ Phone (______)__________________________________

Name of Organization Head:___________________________________ # of Dojo in Org:_______________

Teacher history: 1st___________________2nd___________________ 3rd_____________________________

Styles Studied:_____________________________________________________________________________

Ranks earned/style: ________________________________________________________________________

Association awarding ranks:_________________________________________________________________

Affiliations_____________________________________________________________________________________

By applying for membership, I hereby fully and unconditionally release the IUKF , its Officers and Directors, Certified Instructors and Member dojo from any and all claims for any and all injuries, accidents or losses that I may receive while practicing the martial arts sanctioned by the IUKF.

Signature of Organization Head__________________________________________Date___________________

Credit card payment: Credit card type: MC__ Visa__

Name on credit card:___________________Card number: ________________________________________

Expiration date:________________________

Billing address for credit card: _____________________ City _______________State _________________

Country__________Zipcode:______________

(Note: G&S Consulting processes all credit card transactions)

Date Approved by IUKF______________________ IUKF Membership Number:____________________________