FIMA Membership Application Step 1 of 3 33% Applicant InformationName* First M.I. Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell Phone*Email* Citizenship* Have you ever been convicted of a felony?* Yes No T-Shirt Size* S M L XL 2XL If yes, explain:* *ISRAELI MARTIAL ARTS BACKGROUNDISRAELI MARTIAL ART/STYLENONEKRAV MAGAKAPAPHISARDUTKAVANAHHAGGANAHKALAHOTHERRANK* IF BLACK BELT UPLOAD YOUR CERTIFICATEMax. file size: 80 MB.YOUR INSTRUCTOR NAME SCHOOL NAME / ADDRESS CERTIFIED AS AN INSTRUCTOR?* Yes No YOUR INSTRUCTOR NAME* SCHOOL NAME/ADDRESS* IF INSTRUCTOR UPLOAD YOUR CERTIFICATE*Max. file size: 80 MB.ADDITIONAL ISRAELI MARTIAL ART/STYLENONEKRAV MAGAKAPAPHISARDUTKAVANAHHAGGANAHKALAHOTHERRANK* CERTIFIED AS AN INSTRUCTOR?* Yes No ADDITIONAL MARTIAL ART/STYLE*NONETAEKWONDOBRAZILIAN JIU JITSUAIKIDOJAPANESE JIU JITSUJAPANESEKARATESHOTOKANKYOKUSHINKUNGFUNINJITSUHAPKIDOPHILLIPINOMUAYTHAIOTHERRANK CERTIFIED AS AN INSTRUCTOR? Yes No ADDITIONAL MARTIAL ART/STYLE #2NONETAEKWONDOBRAZILIAN JIU JITSUAIKIDOJAPANESE JIU JITSUJAPANESEKARATESHOTOKANKYOKUSHINKUNGFUNINJITSUHAPKIDOPHILLIPINOMUAYTHAIOTHERRANK* CERTIFIED AS AN INSTRUCTOR?* Yes No ADDITIONAL MARTIAL ART/STYLE #3NONETAEKWONDOBRAZILIAN JIU JITSUAIKIDOJAPANESE JIU JITSUJAPANESEKARATESHOTOKANKYOKUSHINKUNGFUNINJITSUHAPKIDOPHILLIPINOMUAYTHAIOTHERRANK* CERTIFIED AS AN INSTRUCTOR?* Yes No ADDITIONAL INFORMATIONDo you have a military experience?* Yes No what branch of service?* Which country did you serve?* Please consider joining IMCO (International Military Combatives Organization) Do you have law enforcement experience?* Yes No Do you have experience in security?* Yes No Please consider joining SLETA (Security and Law Enforcement Training Association) Do you have weapon experience?* Yes No Please consider joining IWA (International Weapons Association) Do you participate in Israeli Jiu Jitsu, Brazilian Jiu Jitsu, Wresting or Grappling?* Yes No Please consider joining IGDA (International Grappling Defense Association) Do you participate in or have any interest in MMA – mixed martial arts such as UFC or Bellator?* Yes No Please consider joining IMA (Israeli MMA Association) ADD INSTRUCTOR CERTIFICATIONMax. file size: 80 MB.If this application is for FIMA instructor (not recognition certificate) Do you have a completed instructor approval form to upload? If yes you must upload your certificate. Disclaimer and SignatureConsent* I have read and agree with the disclaimer(s)Please accept my application for membership in the Federation of Israeli Martial Arts. I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application may result in discontinuation of membership. T-shirts included with Lifetime membership.Date* MM slash DD slash YYYY
