Name of Institution: ___________________________ Address:____________________________________

City______________________ State______ Zip____________

______ National Collegiate Athletic Association (NCAA)

______ National Association of Intercollegiate Athletics (NAIA)

______ National Junior College Athletic Association (NJCAA)

______ Other, Please specify: _________________________

Name of Coach:__________________________ Address: _____________________________________

Phone:______________________ Email:__________________ School/Club Web Site: _______________

I, _________________, an authorized representative of ______________________, do hereby petition the members of the Eastern Collegiate Judo Association (ECJA) for the acceptance into the organization. I further pledge to recognize the ECJA as the regional representative of Eastern Collegiate Judo to the National Collegiate Judo Association and support the Constitution and By-laws of the association.

Signature of Representative

Date Membership Accepted Signature of ECJA Treasurer

ECJA Annual Dues Enclosed: $35.00 Date:_____________ (Dues due date NOV 1^st 2009)

Please send check or money order payable to Eastern Collegiate Judo Association to:

Hector R. Morales

237A Barnard LpP>

West Point, NY 10996