APPLICATION

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PERSONAL INFORMATION

Full Name: _________________________________
                                           (First, MI, Last)		 Sex: ___
  		 *DOB: _________
   		 *SSN: ___________
 
*Street: ____________________________________     Home Phone: ___________________ 
*City, State, ZIP: _____________________________ *Work Phone: ___________________ 
   *Cell Phone: ___________________ 
E-mail: _____________________________________               *FAX: ___________________ 
Best Way To Contact: __________________________   Best Time To Call: ___________________________
*T-Shirt Size: ______   

CERTIFICATION INFORMATION

Highest Certification Level: _______________ *Certification Number: __________________ *Year: ____
Agency: _______________________________________________
*Certifying Store: _______________________________________ *Store Number: ______
*Store City & State: _____________________________________
*Instructor Name: ________________________________ *Instructor Number: ______________ 

DIVING HISTORY

*Diving Since: ______     *Fresh Water Dives Logged: ______     *Ocean Dives Logged: ______    

 

INTEREESTS

 

Days Available to Dive: _____________________________________________________________________ 
Where do you usually dive: __________________________________________________________________ 
Where would you like to go: _________________________________________________________________


  *This information will not be available to the public.  Any contact information will only be posted if you wish to be contacted as a "Dive Buddy".

  

PREFERENCES

 

[ ] I DO wish to be contacted as a dive buddy                                            [ ] $50.00 Annual Hammerheads Club Membership

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

 

[ ] E-mail newsletters to me                
[ ] Mail newsletters to me                                    

[ ] Send both types newsletters        

Comments/Suggestions:________________________________________________________________

                                        ________________________________________________________________