Name*

E-mail*

Phone #:

Mailing Address:

If you will be visiting the area, and are not a local resident, please indicate where you will be residing during your stay:

Certification Dive Trip

Date(s) Requested:

For Certifications:

Please indicate the type of certification:
(hold down the 'ctrl' key to select multiple certifications)
Select Certification(s)... Discover Scuba Discover Scuba Diving Scuba Diver Open Water Diver Open Water Referral Adventure Diver Advanced Open Water Diver Enriched Air/Nitrox Specialty (please indicate which specialty(ies) in the comments) Emergency First Response Rescue Diver Master Scuba Diver

If you have a preference for the location of your checkout dives, please indicate:

For Advanced Certifications and specialties,
will you be renting equipment? (not including tanks)
Yes No
If yes, please indicate size(s) under comments.

For Dive Trips:

Please indicate location of interest:
(hold down the 'ctrl' key to select multiple locations)
Select Location(s)... Jupiter West Palm Boynton Pompano Florida Keys Springs Marineland Other (Indicate under comments)...

Will you be renting equipment? (not including tanks)
Yes No
If yes, please indicate size(s) under comments.

Would you like a Divemaster?
Yes No