2006 PJU Memberships form

This form must be hand in before the Technical Congress by all Federations, with no exceptions, in order to get the PJU Card:

Annual PJU Membership and Dan Grade Form

For PJU Use Only
Certificate No. _________________ Book No. ______________________ Date: _______________________________________________________

Please print or write down in clear and easy to understand hand writing. Remember that this is the data that will appear in your Membership Card and Diplomas.

Name (Only one name allowed):____________________________________________

Last Name(Only one last name allowed):_____________________________________

Place of birth: ______________________ Nationality:___________________________

Date of Birth: dd/mm/yyyy:______/_____/________

(Passport) or ID Number_____________________________________________________

Addressr:_________________________________________________________________

Country: ______________________________City:_________________________________

Phone: _____________ E-mail:________________________ Ocupation:________________

Belt in Judo: __________________________ (please specify your black belt grade in numbers: 1st, 2 nd, 3 rd etc., if you are not a black belt, please specify the color of your belt).

Last Date you got your Belt Recognition: ______/______/_______(dd/mm/yyyy)

Role: Competitor:______, Official:_______, Referee_______, Coach:_______, Physician______President of NF:______ NF General Secretary:________


_______________________________________	_______________________	__________________________
President of Federation (Federation Seal and President Signature )	Applicant’s Signature	PJU Director Signature (PJU Seal)

Annual PJU Membership and Dan Grade Form