NEIMAA Application Form NEIMAA Black Belt Roster

Instructions: Print and fill out this form (all information marked with a * is a required field) and mail to: N.E.I.M.A.A. c/o Master M. Smith P.O. Box 231 Corinth, Maine 04427 *DATE:__________________________________________________________ *APPLICANT'S NAME:_________________________________________________ *SCHOOL NAME:_________________________________________________ *SCHOOL STYLE:_________________________________________________ *CURRENT BLACK BELT RANK: __________________________________ *INSTRUCTOR'S NAME(S):________________________________________ *MAILING ADDRESS:_____________________________________________ STREET:_______________________________ CITY:_____________________ STATE:______ ZIP:______________ *PHYSICAL ADDRESS (IF DIFFERENT):__________________________________ *PHONE #: ( ) ____-________ E-MAIL ADDRESS: ________________________________________ A FEE OF $25 PER RANK OR A ONE TIME FEE OF $50 FOR CURRENT AND FUTURE PROMOTIONS. FEES ARE PAYABLE BY MONEY ORDER TO N.E.I.M.A.A. A SIGNED COPY OF YOUR RANK PROMOTION CERTIFICATE WILL BE REQUIRED. PLEASE DO NOT SEND AN ORIGINAL. IF NO CERTIFICATES ARE ISSUED, A SIGNED PROOF OF RANK FROM YOUR INSTRUCTOR WILL ALSO BE ACCEPTED.