NYZA ASSOCIATION FORM

Your Name (required)

Your Email (required)

Subject

Title*

First Name*

Last Name Name*

Date Of Birth*

Region*

Are you being referred by someone at Nyza Jiu Jitsu?*  Yes No

If yes, please mention name and email of the Instructor Person referring you*

Home Phone Number*

Work Phone Number*

Cell Phone Number*

Home Fax Number*

Email Address*

Personal Facebook URL

Home Address*

City*

State/Province*

Zip Code/Postcode*

Country*

Is this a new Martial Arts School?*  Yes No

If no, How long have has your school been open?*

Does your school have any other Brazilian Jiu-Jitsu Organization affiliation at the moment? Yes No

If yes, please name the Organization

How many students do you have?

Please approximate students population by rank, (e.g., 50% White Belt, 40% Blue Belt, Etc.)

What is your goal in terms of number of students in your Brazilian Jiu-Jitsu Program?

Is your school in a 20 mile radius of an existing NJJA school? Yes No

If yes, name school address state and country

Name of the head instructor responsible for BJJ program

Rank of the head instructor responsible for BJJ program

Who promoted the instructor responsible for the BJJ program to his current rank?

Please provide active email address of the person who promoted the head instructor to his current rank

What was the date of the instructor's last promotion?

Please provide information on the competition, training and teaching background of the instructor responsible for BJJ Program

Please explain the reasons why you would like to join Nyza Jiu-Jitsu

Please upload recent picture from your facility

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