USA FEDERATION of PANKRATION ATHLIMA

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A NOT-FOR-PROFIT 501 (c)(3) TAX EXEMPT ORGANIZATION

MEMBERSHIP APPLICATION 2007 - 08

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Check The Type Of Membership You Are Applying For

		Athlete	$25.00 Fee
		Coach	$25.00 Fee
		Official	$25.00 Fee
		Club	$50.00 Fee
		State Director	$600.00 Fee (minimum of 12 clubs)
		Regioinal Organization	$750.00 Fee
		National Organization	$3,000.00 Fee
		Disable Organization	$3000.00 Fee
		Public Sector Membership	$10.00 Fee

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Name:___________________________________ Age: _____ DOB: __________ Sex: _____

Address: ______________________________ City: ________________ St: ____ Zip: _______

Phone: (_______)_________________ Fax: (________)_________________

Email Address: _____________________________________________________________

Instructor: ___________________________ Martial Art: ____________________________

Signature: __________________________________ Rank (If Any) ____________________

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Make Check or Money Order Payable To:
USAFPA
and mail to: 1935 South Plum Grove Road, #321, Palatine, IL 60067