Are you a New Associate Renewal

How did you hear about A.T.A.M.A.?  Web   Friend/Instructor   Advertisement

First Name Last Name

Title      Birth Date (mmddyy)      Gender Male Female

Address 1

Address 2

City State None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachutes Michigan Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming   Zip

Country

Phone Number  Work Number FAX

Email 

Web Site

Style Time in Years Rank

Style Category:   Hard     Soft     Grappling     Weapons     Other

Your Instructor's Name

Are you at the Instructor Level Non-Instructor Level

Teaching Preferences (All Instructors)

  Beginners     Advanced     Adults     Children     Weapons 

   Law Enforcement     Women's Self Defense     Other

Instructor Certification  Yes No

  Certifying Organization Date Certified (mmddyy)

Name of School

Address

City State None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachutes Michigan Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming   Zip

Country

Phone Number  FAX

Email 

School Web Site

Owner's Name    Title

A.T.A.M.A. Chapter Name

Current or Former:    A.T.A.M.A. National Officer   A.T.A.M.A. Chapter Officer

Lifetime Associate - (Does not include insurance) $300.00

Adult Associate (Includes Insurance) - $55.00

Junior Associate, Under 18, (Includes Insurance)  - $40.00

School Charter is Optional - $50.00 - (One time fee)
* If you have a school charter we will list your school on the A.T.A.M.A Web Site!!! *

Total Amount Submitted $   Date Paid (mmddyy)

I certify that the foregoing information is correct. I agree to abide by the principles of A.T.A.M.A. with regards to my conduct as an instructor. Any misleading or false statements contained within this application are grounds for dismissal from this organization with forfeiture of all membership fees.

A.T.A.M.A. will not accept membership from those who have had a Felony conviction relating to sexual misconduct or a history of inappropriate behavior relating to martial arts activities.

A.T.A.M.A. RESERVES THE RIGHT TO CONDUCT CRIMINAL BACKGROUND CHECKS ON ANY CURRENT MEMBERS OR ANYONE APPLYING FOR NEW MEMBERSHIP!

Signature of Applicant  Date (mmddyy)

Signed by Parent/Guardian if applicant under 18

Please PRINT this form and then SUBMIT to let us know that you will be mailing this form with your check of either $300 for a Lifetime Membership or $55.00 for an Adult Membership or $40.00 for a Junior Members (Under 17). Mail form to: A.T.A.M.A. National Board, c/o Dr. T. R. Crimi, 11990 Sunset Hill Rd., Penn Valley, CA 95946.