Name:
Address:
City:
Province/State:
Country:
Postal/Zip:
Phone Number:
Email Address:
Age: (must be 30 years plus on the first day of competition August 17th, 2010)
Registration Fee's:	$10.00 if registered for the main tournament. $25.00 if registered for newaza competition only.(all participants must have an active WMJA membership - $30.00 fee.)
Credit Card Type:
Card Number:
Expiry Date:
Name of Card Holder:

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