X hits on this document

13 views

0 shares

0 downloads

0 comments

1 / 2

DIVEMASTER APPLICATION

OFFICE USE ONLY

  • #

    - ____________________________

Cert. Date

______________________

By ____________________________

PLEASE PRINT CLEARLY

Return certification package to:

Dive Center/Resort

Instructor

Applicant

Name __________________________________________________________________________________________________________________

First

Initial

Last

Mailing Address

__________________________________________________________________________________________________________

City ________________________________________________________________

State/Province

______________________________________

Country ___________________________________________________________________________

Zip/Postal Code

______________________

Home Phone (_____)______________________________________ Business Phone (_____)__________________________________________

FAX (_____)__________________________

Email

___________________________________________________

Date of Birth

_______________

D/M/Y

Sex:

M

F Preferred Language _____________________

Where will you work after certification

___________________________________

Country

PREREQUISITE REQUIREMENTS

Must be PADI Advanced Open Water Diver, PADI Rescue Diver and Emergency First Response Primary Care (CPR) and Secondary Care (First Aid), or hold qualifying certifications from another organization. Copies of ALL non-PADI certifications must be attached to this application.

_____________________________

________________________________

Student Number

Student Number

PADI AOW

PADI Rescue

EFR

______________________________

Student Number

DIVEMASTER CERTIFICATION INFORMATION

This Application must be signed by the applicant and the certifying instructor (a PADI Open Water Scuba Instructor or higher level).This application does not constitute membership. Membership is activated only upon review and approval of this application by PADI.

PADI Divemaster Course Completion Date

________________

Course Location

____________________________________________________

D/M/Y

City/State/Province/Country

Certifying Instructor Name ________________________________________________________ Phone (_____)____________________________

Dive Center/Resort Name ____________________________________ Store No. ___________ Phone (_____)___________________________

I have read the Membership Agreement,* and License Agreement,* and hereby consent and agree to the terms and conditions in their entirety. I understand and agree that any criminal conviction on my part involving abuse of a minor or sexual abuse of an adult occurring either during or prior to my membership with PADI, will be automatic grounds for denial or termination of my PADI Membership. I hereby certify that all the above statements are true and correct to the best of my knowledge.

Applicant’s Signature

________________________________________________________________

Date

________________________________

Signature — Required

D/M/Y

I certify that all prerequisites and certification requirements have been met as outlined in the PADI Instructor Manual.

Certifying Instructor

_________________________________________________________

PADI No.

_______________

Date

________________

Signature — Required

D/M/Y

I verify the applicant has logged 60 dives. Initials of verifying instructor *Agreements are found in Divemaster Crew-pak or may be obtained from your instructor.

_____________

PADI No.

_____________

PRODUCT NO. 10144 (Rev. 1/08) Version 4.05

page 1 of 2

© PADI 2008

Document info
Document views13
Page views13
Page last viewedThu Oct 27 07:46:14 UTC 2016
Pages2
Paragraphs131
Words619

Comments