APPLICATION

THIS FORM IS NOT INTERACTIVE YET.  PLEASE COPY AND MAIL OR E-MAIL

PERSONAL INFORMATION
*THIS INFORMATION WILL NOT BE MADE AVAILABLE TO THE PUBLIC.
OTHER CONTACT INFORMATION WILL ONLY BE GIVEN OUT IF YOU WISH TO BE CONTACTED AS A DIVE BUDDY
.

Last: ______________    First: ______________    MI: ______________    Suffix: _____    Maiden: _____________
Sex: ___    DOB: ________    SSN: ___________                                                         Phone Home : ____________
                                                                                                                                                  Mobile: ____________
Business: ______________________________                                                                         Work: ____________
Apt/Box: ___________    Street: ________________________                                                 FAX: ____________
City: ________________________    State: _____________    ZIP: __________
E-Mail: _____________________________

PREFERANCES

[  ] I do wish to be contacted as a dive buddy                            Club Fees:    [  ] $50.00 Annual Club Membership

[  ] I do not wish to be contacted as a dive buddy                                            [  ] $25.00 Each additional family member

[  ] E-mail newsletters to me                                                                        Total: $______
[  ] Mail newsletters to me                                                                                          Membership Expires: ________
[  ] Send both types newsletters                                                                  # and Shirt Sizes: ___________________

INTERESTS

Days available to dive: _________________________________________________________________________

Where do you usually dive: ______________________________________________________________________
Where would you like to go: _____________________________________________________________________

DIVING HISTORY

Diving Since: ____    Total Dives: ______    Fresh: ______    Ocean: ______
Highest Certification Level: ______________________    Certification Number: __________________________
Certification Agency: ___________    Certification Date: ________
Store: ______________________    Store Number: ______    City & State: _____________________________
Instructor's Name: __________________________    Instructor's Number: _________
Comments/Suggestions: ______________________________________________________________________
                                     ______________________________________________________________________
                                     ______________________________________________________________________

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