Applications " Please attach recent photo" and Application fees                                                          

 

 

INTERNATIONAL BLACK BELT ASSOCIATION

APPLICATION FORM

PRINT OUT AND MAIL TO:

 

I.B.B.A. Board Headquarters

3661 Coral Ridge Court

Sierra Vista, AZ. 85650

 

 

INDIVIDUAL MEMBERSHIP APPLICATION FORM:

( MUST BE EIGHTEEN 18 YEARS OLD )

 

Please print

 

Full Name:_____________________________________________

 

Date of Birth: ___/___/___.

 

Current Address ( no P.O. Box ):____________________________

_____________________________________________________

_____________________________________________________

 

Home Phone (    )___________ Business Phone (    )____________

 

Martial Arts Affiliations: ( Please provide names, addresses, and

 

phone numbers )________________________________________

 

_____________________________________________________

 

_____________________________________________________

 

 

Have you ever been convicted of a felony or charged with any sexual

 

offense?  ( circle one )   NO       YES

 

If yes, explain in detail. What?  Where?  When? , Final disposition of

 

the case: ______________________________________________

 

______________________________________________________

______________________________________________________

 

Dates, Rank, Issuing association, and any information you think is

Important.

 

A copy of all rank certificates reduced to letter size must accompany

Application.

 

1.    _________________________________________________

2.    _________________________________________________

3.    _________________________________________________

4.    _________________________________________________

5.    _________________________________________________

 

Martial arts association affiliations (current and past)

 

1.    _________________________________________________

2.    _________________________________________________

3.    _________________________________________________

 

Would you like to receive more information about our Insurance plans? (Circle one) YES NO

 

A one time non-refundable processing fee of $25.00 MUST ACCOMPANY APPLICATION, This fee is in addition to the first year membership fee of $35.00. All fees must be remitted at time of application. An IBBA RANK CERTIFICATE, POCKET CARD, AND PATCH will be issued when all information provided has been verified. Renewals must be paid annually before January 15th.

 

                                                                                                            Date:___________

 

SIGNATURE REQUIRED

 

*********************************************FOR OFFICIAL USE ONLY**********************************

 

Date received:________________Processed by:________________________Comments

 

 

Approved by: IBBA BOARD MEMBER:

 

 

DATE: MEMBERSHIP ISSUED: