Respecting the past, Creating the future!
AIKIA Application
________________________________________________________________________________________________________
(Name) (Date of Birth) (e-mail address/web site)
________________________________________________________________________________________________________
(Street address)(Apartment or P. O. Box number)
________________________________________________________________________________________________________
(City) (State) (Zip code) (Phone number)
In _________ (year) I received the 1st degree black belt from my instructor ___________________________________ (name of instructor) whose school was/is located at _______________________________________________________________________ (address of school).
Include a copy of all black belt certificates. Any misinformation may result in forfeiture of your application fee.
Fee: $229 includes the Black Belt member certificate, Black Belt Instructor certificate and Black Belt Agent certificate, two patches, the Dojo Dynamics book and use of one of the following logos for advertising:
Use the logos to promote your school in all forms of advertising (not to include any documents of rank or membership) including T-Shirts, gis, advertisements, posters, flags, etc. The AIKIA certificates of rank include each logo.
The yearly renewal fee is only $99 or you may request an AIKIA Lifetime Agent membership for only $995 (includes the initial $199 fee.)
Please find my fee of _____________ enclosed (please use money order).
Dr. Jerry Beasley
P. O. Box 402
Christiansburg VA 24068
