The Martial Arts Network Charter Member Application 11435A Palmetto Park Rd. Boca Raton, FL 33428 407-482-9049 407-482-1896 (fax) http://www.martial-arts-network.com/ E-Mail RonT398675@aol.com Charter Member Profile Enrollment Date: _____________ Occupation: ________________________ Gate Code: ____________ Mr./Mrs./Ms.: ______ SS#: ______-___-______ First Name: ________________ Last Name: ___________________________ Address Line 1: ___________________________________________________ Address Line 2: ___________________________________________________ City: __________________________ State: _______ Zip Code: ________ Phone 1: _(_____)______________ Fax Line: (_____)_________________ E-mail Address _______________________________________________ School Owner Membership: $99/yr Charter Member Membership: $39/yr General Membership: $19.95/yr Martial Arts Scout Membership: $50/yr Visa/Master Card: _____________________________ Exp. Date: _______ American Express: _____________________________ Exp. Date: _______ Employment Information: Company: _________________________________ Years Employed: ______ Address: ______________________________________________________ City: _____________________ State: _________ Zip Code: __________ Phone Number 2: (____)_____________ Contact Person: _____________ Personal Information: Are You A School Owner (Yes/No): ___________ Years Training: _____ Martial Arts School: __________________________________________ School Address: _____________________________________________ City: _______________________ State: _______ Zip Code: __________ Your Rank: ____________ Style: _______________Country of Origin_________ Weapons Training: ______________________________________________ Your Instructors Name: _________________________Instructor's Rank_______________ Comments: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Education: Name of High School: ___________________________________________ Name of College or Trade School: ___________________________________ Licenses: ______________________________________________________ _____________________________________________________________ _____________________________________________________________