MEMBERSHIP FORM AND GRADE DAN CERFICATION

National Judo Federation: _________________

Foto N°:_________

PJU Exclusivly

Certificate No _________________   Book No.___________________

Date: ____________________________________________________ 

Name (only one):_______________________Last Name (only one):_____________________

Place of Birth: ____________(Country)___________ Nationality:________________________

Date of Birth: dd/mm/yyyy:___/___/_______(N° Passport or ID No. ___________________________

Home Address:_______________________________________________________________
Country :___________________________City: _____________________________________
Telephone:___________E-mail:______________Occupation: _________________________

Judo Grade: ______________________ (Use numbers, if you are not Dan write the color of your belt).

Date of last Dan exam: ____/_____/______(dd/mm/yyyy)

I assurance all this form given information is true, if demonstrate it is not I will accept disciplinary measurement needed because given false information. I accept all rights of this event are property exclusive of Pan American Judo Union and as a consequence total or partial reproduction of videos, photos or any other graphic material is forbidden without authorization of Panamerican Judo Union.  I will also allow to be film, photo, etc, any moment of the event and I give away all the rights by myself to Panamerican Judo Union, in the same way I will refrain of money complaining, demanding or requesting because of accidents, injuries or possible illness could have place in the event to Dominican Judo Federation, Pan American Judo Union or Organizing Committee.

    ______________________________________________________________________________________________
Name, Sign and ID number

__________________________
 
Signature National Federation President
(Seal of National Federation)

__________________________

Signature PJU Education Director
  (Seal of PJU)