SCUBA CLUB APPLICATION

APPLICATION

THIS FORM IS NOT INTERACTIVE. 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
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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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