Individual PKC Membership Form
Please allow 3-4 weeks for processing. New Members will receive a membership card, certificate, and PKC patch. Lifetime members will receive a special gold certificate, laminated membership card, 2 Lifetime Patches, and a gold Lifetime lapel pin.
If you do not have a credit card and would like to become a member... simply fill out the form below leaving out the credit card information, print the form & mail it with your check or money order payable to Glenn Keeney
mail to:PKC Headquarters...P.O. Box 20936, Hot Springs, AR 71901
First Name:
......
Payment Information:
Last Name:
Please Choose One:
$30 Membership
Email:
$200 Lifetime Membership
Birthdate:
$20 Renewal
Gender:
Male:
Female:
Phone:
CC Type:
Visa
Street Address:
MasterCard
City:
Province/State:
Postal Code:
Cardholder's Name
Country:
UNITED STATES
CANADA
PUERTO RICO
UNITED ARAB EMIRATES
UNITED KINGDOM
VIRGIN ISLANDS (BRITISH)
VIRGIN ISLANDS (U.S.)
Other
Card Number
Rank(color/kyu):
Card Expiration Date
Style of Martial Arts:
Verification #
(3 digit number)
Instructor's Name:
THANK YOU!
Dojo Street Address:
SSL Certificates
DojoCity:
Dojo Province/State:
Dojo Postal Code/Zip:
If you have any questions or comments, please write to us below:
This form and its
form processor
supplied by www.tectite.com.