Contact:

Name:________________________________________________

Address:______________________________________________

Phone:________________________________________________

Email:_________________________________________________

School Name: ____________________________________________________

Address: ________________________________________________________

Phone:_______________________________ Fax: _______________________

Web Site:_______________________________________________

Main Brazilian Jiu Jitsu Instructor:

Name: ______________________________________________________

Rank: _______________________________________________________

#of years teaching Brazilian Jiu Jitsu: ______________________________

#of years training Brazilian Jiu Jitsu:_______________________________

Your instructors name and rank: ___________________________________

If under a Brazilian Jiu Jitsu organization please list: ___________________________

Please briefly explain your intent and reason for wanting to be a part of the North Carolina

Brazilian Jiu Jitsu Federation:_____________________________________________

___________________________________________________________________

Please briefly list why you feel that your school should become an endorsed school with

the North Carolina Brazilian Jiu Jitsu Federation._______________________________

___________________________________________________________________

* Main Instructor must also send photocopy of valid CPR certification in order to become eligible.

* send 2 passport size photos ( 2 x 2 ) with application.