PKC Membership Form

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:				American Express
Province/State:
Postal Code:			Cardholder's Name
Country:			Card Number
Rank(color/kyu):			Card Expiration Date
Style of Martial Arts:			Verification #	(3 or 4 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:

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