United States Jiu Jitsu Alliance        

Printable Membership Application

A Copy of Your Instructor Signed Rank Certificate Must Be Provided

 Name________________________________________________ Date Of Birth___________________________

 Address____________________________________________________________________________________

 E-Mail Address (if available)____________________________ Phone Number (if available)___________________

 School Name___________________________________ Name Of Instructor _____________________________

 Year You Began Martial-Arts Training_____________________ Main Style You Study______________________

                                                                      Style(s) and Rank(s) (If necessary write on back)

 Style________________________________________________ Rank____________________________________

 Style________________________________________________ Rank____________________________________

                                                           Check The Box Next To The Membership (s) You Would Like

    [   ] Black Belt Rank Recognition $20.00

    [   ] Individual  Lifetime Membership $25.00

    [   ] Club / School / Organization Lifetime Membership $30.00

Explain any Specifics:_____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 Print Clearly On The Appropriate Lines Below How You Want Your Certificate To Read

Name (how you wish it to appear on your certificate) ________________________________________________

Club Name (how you wish it to appear on your certificate) ___________________________________________

Style (how you wish it to appear on your certificate) ________________________________________________

Rank (how you wish it to appear on your certificate) ________________________________________________

  I, _________________________________, hereby acknowledge that the information provided above is true and accurate. I also have read the United States Jiu Jitsu Alliance Mission Statement, Disclaimer and Code Of Conduct. In addition I agree to uphold the integrity and represent the U.S.J.J.A. with dignity and honor.  Any violation of the U.S.J.J.A. Code Of Conduct will result in me forfeiting my membership and recognition. 

Signature _____________________________________Date_______________________

Please make payment payable to U.S.J.J.A.

Print Application Out And Mail to:

U.S.J.J.A., c/o Shihan Jay Sandlin, 6768 Courtney Lane, Greenville, Ohio 45331