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: $100 includes the Black Belt member certificate, Black Belt Instructor certificate and Black Belt Agent certificate, two patches, and the Dojo Dynamics book.
Use the following MMA Trainers Association/Karate College logo if your school participates at the annual Karate College Martial Arts Training Camp:
The yearly renewal fee is only $99 or you may request an AIKIA Lifetime Agent membership for only $995 (includes the initial $100 fee.)
Please find my fee of _____________ enclosed (please use money order).
Dr. Jerry Beasley
P. O. Box 402
Christiansburg VA 24068
