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PAYMENT METHOD See current price list for payment information.

CARD OPTIONS

PADI Standard Card (no additional fee)

  • MasterCard

  • Discover Card

  • VISA

  • JCB

  • American Express

  • Maestro/Solo (UK only)

To help preserve the aquatic environment, please select and indicate the amount of donation:

  • Check/Bank Draft Number* ______________________________

*Check/Bank Draft must be payable in the currency of the PADI Office the application is submitted to.

Card Number __________ __________ __________ __________ Cardexpirationdate__________Securitycode_________________ Maestro/Solo valid from date ______ Or Issue No. _____(UK only) Cardholder Name ______________________________________

Please Print

Project AWARE Foundation Card (Contact your PADI Office for minimum donation)

_________

Additional Project AWARE Foundation donation (A donation of any amount is appreciated)

_________

PLEASE DO NOT WRITE IN THIS SPACE

Date

____________________________

Amount

_________________________

Authorized Signature

___________________________________

CHECKLIST

Application completed in full

Prerequisite information completed and required documentation attached

MAIL TO: Your PADI Office Attn. Divemaster Certification For mailing information, see current price list or visit padi.com.

Tape / Attach a 4.5cm x 5.7 cm 1 3 4 " x 2 1 4 " ( a p p r o x . )

Applicant and instructor signatures One photo attached (print name on back)

Please check box if DSD Internship Completion form is attached #10151

Head and Shoulder Photo

PRINT NAME ON BACK OF PHOTO

See price list for fee (Fee includes a quarterly subscription to The Undersea Journal valued at $12 or equivalent in local currency.)

Coin Machine Photos OK No Dark Glasses

Rec’d

______________________________

Ent

______________________________

Shp’d

______________________________

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