WPO Affiliation Form
All material should be sent by mail to the general secretary office at:

World Pankration Organization
6 Hamanof St.
Rehovot 76386
Israel

First Name 1

Last Name 1

Date of Birth Month: Day: Year:

Sex Male Female

Address 1

City 1

State 1

Zip Code 1

Tel 1

Fax 1

E-Mail 1

Experience in Martial Arts:

Style Belt Years of Training In which Association

x x x x

x x x x

x x x x

x x x x

x x x x

* Please enclose photocopies of higher ranks certificates

Are you a martial arts instructor or coach? please specify style, organization and where qualification was held, please enclose photocopy of certification and of grading transcript if available.

x

x

x

x

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First Name	1
Last Name	1
Date of Birth	Month: Day: Year:
Sex	Male Female
Address	1
City	1
State	1
Zip Code	1
Tel	1
Fax	1
E-Mail	1

Style	Belt	Years of Training	In which Association
x	x	x	x
x	x	x	x
x	x	x	x
x	x	x	x
x	x	x	x