PKF MEMBERSHIP APPLICATION

First Name______________________________________ Last Name________________________________________

Nickname__________________________________Sex_____________D-O-B_____________________Age__________

Address___________________________________________________________________________________________

City_________________________________________State___________________Zip code______________________

Home Phone#_________________________________ Cell Phone #________________________________________

Height____________________Weight______________________Occupation________________________________

         Amateur______________________________ or Professional____________________________

     Wins_______ Losses_______ Draws_______          Wins_______ Losses_______ Draws_______

Titles Held_______________________________________________________________________________________

*All Professionals must also complete the Amateur section

‚ÄčOrganization (s) fought under_______________________________________________________________________

Trainer's Name____________________________________________ Phone #________________________________

Manager's Name___________________________________________ Phone #_______________________________

Name of Gym representing__________________________________________________________________________

    I, the undersigned do here by voluntarily submit my application for membership in the Professional Kickboxing Federation (PKF) and understand that I am participating in a FULL CONTACT SPORT.  I assume full responsibility for any and all damages, injuries and losses that I may sustain while participating in a PKF championship.  I also waive all claims against any and all persons and groups associated with the Professional Kickboxing Federation, sponsors and sanctioning organizations.

    I understand that any medical treatment given me will be of first-aid type only.  I consent that any pictures furnished by me or any picture taken of me in connection with PKF Championships can be used for publicity, promotion or television showing and I waive compensation in regard thereto.

    I also certify that I will read, or have read the PKF Championship contestant and registration rules, and will abide by its rules and interpretation of these as outlined by the promoter or his agents.

         ________________________________________                  __________________________________________________

                       APPLICANTS SIGNATURE                                      IF UNDER 21 Yrs OF AGE PARENT OR GUARDIAN SIGNATURE


         ________________________________________                              ________________________________________

                    DATE APPLICATION SIGNED                                                               SIGNATURE OF NATARY PUBLIC

MAKE CHECK PAYABLE TO: JONAS NUNEZ JR. SEND $30.00 FEE TO

                                          126 ELMORA AVENUE ELIZABETH NEW JERSEY 07202

‚Äč                                          (IF PAYING IN CASH PLEASE DO SO IN PERSON DO NOT MAIL)