WAKOGB Online Membership Application Form

This is the form to fill in and submit following purchase of Insurance / Membership. Please fill it in immediately after purchase and submit.

Order Number*

Please put your order number confirmation here. It can be found on the email that was sent to you after your purchase. (This means that you need to purchase from the shop the type of membership you want prior to completing this form.) This tells us who this application belongs to.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Number*
Email*
Date of Birth*
DD slash MM slash YYYY

DD/MM/YYYY
Gender*
- Male
- Female
Present Grade*

Please put UNGRADED if you have never graded with WAKO
Instructor / Student*
- Instructor / Coach
- Student
Club Name*
Club Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Club Email
Club Contact Number
Club Website

FIRST NAME	SURNAME	GENDER	DOB DD/MM/YYYY	STUDENT / INSTRUCTOR