Surname
First Names
Address
Sex
Male Female
Postcode
e-mail address
Date of Birth
(dd/mm/yyyy)
Previous BJA Licence No
Licence expiry date
Club Name
Club number
County you wish to represent
<default to home address> London/London Berkshire/Northern Home Counties Oxfordshire/Northern Home Counties Kent/Southern Surrey/Southern Sussex/Southern Hampshire/Southern Jersey/Southern Isle of Wight/Southern Essex/Northern Home Counties Hertfordshire/Northern Home Counties BedfordShire/Northern Home Counties Middlesex/Northern Home Counties Buckinghamshire/Northern Home Counties Leicestershire/Midlands Lincolnshire/Midlands Nottinghamshire/Midlands Northamptonshire/Midlands Derbyshire/Midlands Warwickshire/Midlands Worcestershire/Midlands West Midlands Metro/Midlands Staffordshire/Midlands Shropshire/Midlands Cheshire/North West Lancashire/North West Merseyside/North West Isle of Man/North West Cumbria/Northern Tyne & Wear/Northern Cleveland/Northern Humberside/Yorkshire & Humberside Yorkshire/Yorkshire & Humberside Gloucestershire/Western Wiltshire/Western Devon/Western Cornwall/Western Dorset/Western Bristol City/Western Cambridgeshire/Eastern Somerset/Western Suffolk/Eastern Norfolk/Eastern Royal Navy Royal Air Force Herefordshire/Midlands
Please select the category that best describes your ethnic group
<Please select Ethnic Group> British Irish Any other White background (please specify in box below) White & Black Caribbean White & Black African White and Asian Any other mixed background (please specify in box below) Indian Pakistani Bangladeshi Any other Asian background Caribbean African Any other Black background (please specify in box below) Chinese Any other (Please specify in box below) No Information Provided Other (if applicable)
DISABILITY The Disability Discrimination Act 1995 defines a disabled person as anyone with a “physical or mental impairment that has a substantial and long term adverse effect upon his/her ability to carry out normal day to day activities.
" If you consider yourself to have a disability, please choose the description that best describes the nature of your disability and enter the code (and write in other description where appropriate) on your application
None Visually Impaired Hearing Impaired Physical Disability Learning Disability Multiple Disability Other (please specify in the box below) Other disability (if applicable)
The British Judo Association is registered under the terms of the Data Protection Act and wishes to include the information you have provided on this application on the BJA database for the purpose of administration and maintenance of membership records, provision and administration of activities, support and fund raising. Please complete the following section to indicate your consent to this process. I consent for the information on this application form being included on the BJA Database.
LICENCE CATEGORY
FEE LICENCE ONLY
SENIOR NEW LICENCE
+16 years/issued for one year/valid for all activities
£32
SENIOR RENEWAL LICENCE +16 years/issued for one year/valid for all activities
£31
SENIOR RENEWAL TWO YEAR LICENCE +16 years/issued for two years/valid for all activities
£62
JUNIOR NEW LICENCE
-16 years/issued for one year/valid for all activities
£21
JUNIOR RENEWAL LICENCE -16 years/issued for one year/valid for all activities
£20
JUNIOR RENEWAL TWO YEAR LICENCE -16 years/issued for two years/valid for all activities
£40
KANO LICENCE 5-8 year old membership
BJA Record Book issued free of charge with new Senior or new Junior Licence
RECREATIONAL LICENCE +16 years/issued for one year/not valid for gradings or competitions
£18
INTRODUCTORY LICENCE (SENIOR) +16 years/issued for 3 months not valid for grading or competition(maximum 3 renewals allowed)
£6
INTRODUCTORY LICENCE (JUNIOR) -16 years/issued for 3 months not valid for grading or competition(maximum 3 renewals allowed)
£4
BJA Record Book may be purchased with Recreational or Introductory Licences
£2.50
DECLARATION
I certify that to the best of my knowledge and belief, the information given in this application is correct. If accepted as a licence holder of the British Judo Association, I agree to abide by the Articles of Association and Bye-Laws together with any amendments made during the term of my licence.
I agree to comply with The BJA Child Protection Policies & Procedures and doping control procedures.
PAYMENT DETAILS Acceptable cards VISA /MASTERCARD /ACCESS /SWITCH
CREDIT/DEBIT CARD NUMBER
CARD EXPIRY DATE
(mm/yy)
CARD HOLDERS NAME
I confirm that I am the authorised card holder for the credit/debit card detailed above.
ISSUE NUMBER (Switch Users Only)
Please note that we are unable to accept Solo, Electron or AMEX cards
The information provided on this form is encoded and transferred securely to us VIA SSL (Secure Socket Layer). .