PJU Memberships form 2006

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

Date of Form Issuance: Day________ Month_____________ Year_______

Please print or write down in clear and esay to understand hand writing. Remember that this is the data that will appear in your Memebership 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:______/_____/________ Blood Type:__________________

ID Number ___________________ (Passport)_____________ (C.I)_____________

Room Number:______________________________E-mail:_________________

Country: _________________________ Phone: _____________

Proffession:__________Academic Level in Education:________

Languages you speak: English: ____ Spanish:_____French:____Portuguese ____

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)

Year when he started Judo: _______ Competitor_______ No competidor_________

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

Annual PJU Membership and Dan Grade Form