NEIMAA Aplication Form School Membership

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:__________________________________________________________ *SCHOOL NAME:_________________________________________________ *SCHOOL STYLE:_________________________________________________ *SCHOOL OWNER'S NAME:________________________________________ *INSTRUCTOR'S NAME(S):________________________________________ *INSTRUCTOR'S RANK(S):________________________________________ *NUMBER OF STUDENTS:_________________________________________ *MAILING ADDRESS:_____________________________________________ STREET:_______________________________ CITY:_____________________ STATE:______ ZIP:______________ *PHYSICAL ADDRESS (IF DIFFERENT):__________________________________ *PHONE #: ( ) ____-________ E-MAIL ADRESS: ________________________________________ *STYLE(S) TAUGHT:__________________________________________ __________________________________________________________________ *NUMBER OF BELT RANKS BELOW BLACK BELT: (IN YOUR STYLE)________ *HIGHEST BLACK BELT RANK YOU CAN ACHIEVE: (IN YOUR STYLE)_______ WILL YOU BE REQUESTING N.E.I.M.A.A. TO OFFICIATE ANY OF YOUR SCHOOL'S RANK PROMOTION TESTS? (CIRCLE ONE) YES    NO ARE THERE ANY SPECIAL REQUIREMENTS YOU WISH THE ASSOCIATION TO HANDLE? IF SO, PLEASE EXPLAIN WHAT THEY ARE. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ MEMBERSHIP FEE FOR SCHOOL PER YEAR: $50.00 (U.S.) PAYABLE BY MONEY ORDER TO N.E.I.M.A.A. A COPY OF YOUR SCHOOLS RANK PROMOTION CURRICULUM WILL BE REQUIRED. PLEASE DO NOT SEND AN ORIGINAL CERTIFICATE.