OFFICE USE ONLY
PLEASE PRINT CLEARLY
Return certification package to:
Home Phone (_____)______________________________________ Business Phone (_____)__________________________________________
Date of Birth
F Preferred Language _____________________
Where will you work after certification
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.
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
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.
Signature — Required
I certify that all prerequisites and certification requirements have been met as outlined in the PADI Instructor Manual.
Signature — Required
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.
PRODUCT NO. 10144 (Rev. 1/08) Version 4.05
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© PADI 2008