Bahamas Dive Club

Membership Application

Name _________________________________________________________________________

E-mail _________________________________________________________________________

Mailing address _________________________________________________________________

_________________________________________________________________

Phone number (H) ______________________________________

(W) ______________________________________ (C)__________________________________

Emergency contact person ________________________________________

Emergency phone number ________________________________________

Certification date _____________________________ Certified by ________________________

Certification level _____________________________ Diver # ____________________________

Dive preferences (check all that apply)

Wreck __ Reef __ Wall __ Night __ Other __________________________________________

Office Use Only

Date paid ___________ Amount _____________ Card issued _________________

Signature _______________________________________________________

Name _________________________________________________________

Amount paid _________________ Date ___________________________

For _____________ dues

Signature ______________________________________________________

10/2007