application

*USA FEDERATION of PANKRATION ATHLIMA*
A NOT-FOR-PROFIT 501 (c)(3) TAX EXEMPT ORGANIZATION MEMBERSHIP APPLICATION 2005
*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)

Regional Organization	$750.00 Fee

National Organization	$3,000.00 Fee

Disabled Organization	$3,000.00 Fee

Public Sector Membership	$10.00 Fee
Name:___________________________________ Age: _____ DOB: __________ Sex: _____ Address: ______________________________ City: ________________ St: ____ Zip: _______ Phone: (_______)_________________ Fax: (________)_________________ Email Address: _____________________________________________________________ Instructor: ___________________________ Martial Art: ____________________________ Signature: __________________________________ Rank (If Any) ____________________

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