Dixie Divers Instructor Academy

1645 South East 3^rd Court, Deerfield Beach, FL 34950

(954) 420-0009   Fax (954) 420-0380

APPLICATION

Name_____________________________________________  Birthdate __________________Sex______

Address________________________________  City______________________State_______ Zip_______

Phone No.______________________ Work Phone No.___________________S.S. No._______________

No. of logged Dives__________________________

CURRENT SCUBA CERTIFICATIONS

Initial Certification:                              Advanced Certifications: (if any)

Level__________________ Level___________________Level________________ Level______________

Assoc._________________ Assoc.__________________Assoc._______________ Assoc._____________

Cert. Date______________ Cert. Date_______________Cert. Date____________Cert. Date__________

Instructor_______________ Instructor________________Instructor____________Instructor___________

Location________________Location_________________Location_____________Location____________

PADI Student #__________PADI Student #___________PADI Student #________PADI Student #_____

                         (If any)                             (If any)                             (If any)                      (If any)

DESIRED COURSES

Courses:                                Start Date:                                             Deposit:

________________________    __________________________________    ________________________

________________________    __________________________________    ________________________

________________________    __________________________________    ________________________

                                                                        TOTAL DEPOSIT _______________________

PAYMENT METHOD

Enclose check or money order payable to DDIA or charge to:

        MasterCard              VISA              Discover Card

Card No.____________________________________________

Expiration Date_______________________________________

Cardholder Name_____________________________________

                                     (Please Print)

Cardholder Signature_______________________ Date_______

*P.A.D.I. Instructor Exams are scheduled at the end of every Instructor Development Course

*All appropriate materials must be read prior to participation in each program. See How to Order Materials form.