Name_____________________________________________________ Date ___________________
Address ____________________________________________________________________________
____________________________________________________________ Zip ___________________
Home Phone (______)____________________ Office Phone (________)________________________
e-mail address _______________________________________________________________________
Age _____________ Occupation ____________________________________________________
Certification (NASDS, NAUI, PADI, etc.) ________________________ Cert. No. ________________
List three wreck dives (within the last two years) that you
have made.
Give the wreck’s name, location, depth , date and name of
the dive boat or captain.
(1) __________________________________________________________________________________
(2) __________________________________________________________________________________
(3) __________________________________________________________________________________
Other diving experience __________________________________________________________________
_____________________________________________________________________________________
Special Interests (artifact collecting, photography, spearfishing, etc.) ___________________________________
_____________________________________________________________________________________
Other information relating to you diving interests and experience? ____________________________________
_____________________________________________________________________________________
Your signature below indicates your willingness to abide by
the safety rules of the club and to abide by the constitution
and by-laws of the club.
Signed: _________________________________________________
Date _____________________