Name (complete)

Date of Birth (dd/mm/yyyy)

Passport Number

Address

AddressPostcode

City

Province/state

Phone

Phone (emergency)

Email

Do you have a diving qualification? Do you have a diving qualification? Yes No

Organization certifying your diving qualification

Level of certification

Total Dives

Maximum depth reached

Last dive (month and year)

Do you have dive insurance? Do you have dive insurance? Yes No

Insurance organization

Insurance/Licence number

Date of expiry of the insurance (dd/mm/yyyy)

Jacket (size)

Do you need to rent diving equipment? Do you need to rent diving equipment? Yes No

Dive-Suit (size)

Fins (size)

Booties (size)

Regulator

Air Tank (12L or 15L)

Observations

Terms and conditions of use Terms and conditions of use I accept the terms and conditions of use.