Freediver Instructor Freediver Instructor
Guide Code:
APPLICATION ______________________________
PLEASE PRINT CLEARLY Return certification package to: Dive Center/Resort Instructor Trainer Applicant
Please check here if this is a change of address and you want our records changed accordingly
DANIEL NARANJO RESTREPO 231746
Name _________________________________________________________________________________________ PADI No. ______________________
First Initial Last
AV SUR No 87-12 TORRE 2 APTO 104
Mailing Address _______________________________________________________________________________________________________________
PEREIRA ROSARALDA
City _________________________________________________________________________ State/Province ___________________________________
COLOMBIA
Country _____________________________________________________________________ Zip/Postal Code __________________________________
057-3122892000
Home Phone (______) ____________________________________________________ Business Phone (______) ________________________________
danielnr1967@[Link]
Email ________________________________________________________________________________ 25-03-1967
Date of Birth __________________________
Day/Month/Year
Gender Identity: Man/Male ESPAÑOL
Woman/Female Non-binary/Non-conforming Prefer not to say Preferred Language _____________________
To apply for and qualify as a PADI Freediver Instructor, meet prerequisite certification and training requirements as follows:
PADI Master Freediver*
or hold both of the following:
PADI OWSI certification
PADI Advanced Freediver*
or hold both of the following:
Qualifying freediver instructor certification*
PADI Advanced Freediver*
18 years old
Current medical statement signed by a physician within the previous 12 months
Emergency First Response (CPR/first aid) training withing 24 months*
Completed one of the following:
PADI Freediver Instructor Training course
PADI Freediver Instructor Orientation (for qualifying freediver instructors from other organizations)
Bonai re
Course Location _______________________________________________________________________________________ 10 Apri l2024
Date ___________________
Day/Month/Year
Dive Center/Resort Name ________________________________________________________________________________ S – ___________________
Jesse duboi sJazzar
Trainer Name __________________________________________________________________________________________ 389619
No. ___________________
Instructor Trainer Signature ______________________________________________________________________________________________________
*Qualifying certifications from other organizations may be eligible.
Submit a copy of your qualifying course(s) with the application for review.
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PRODUCT NO. 10416 (Rev. 11/23) Version 1.03 © PADI 2023
Instructor Acknowledgment
“I agree to follow the PADI Freediver Program standards and understand that I may conduct the course(s) only after receiving written
approval from my PADI Regional Headquarters.
I have read the Membership Agreement and License Agreement (found in the Appendix of the PADI Freediver Program Instructor Guide)
and hereby consent and agree to the terms and conditions in their entirety. I understand and agree that any criminal conviction on my part
involving abuse of a minor or sexual abuse of an adult occurring either during or prior to my membership with PADI, will be automatic
grounds for denial or termination of my PADI Membership. I hereby certify that all the above statements are true and correct to the best of
my knowledge.”
10 Apri l2024
Instructor Signature ___________________________________________________________________________ Date ____________________________
Day/Month/Year
PAYMENT METHODS CARD OPTIONS
See current price list for application fee*.
PADI Standard Card (no additional fee)
American Express MasterCard VISA
08-27
Card expiration date _____________________
Support conservation – donate to receive the PADI AWARE
Foundation™ version of your certification card:
Card Number 4593560925791350
_________ _________ _________ _________ PADI AWARE Foundation Card __________
Cardholder Name daniel naranjo restrepo
_______________________________________ (Please indicate the amount of your donation.
Please Print Minimum of 10 AUD, CDN, CHF, EURO, GBP, or USD)
Authorized Signature _____________________________________ CHECKLIST
Fees sent by bank transfer (Please include applicant’s full name, Application completed in full
PADI Member number (if available) and note which credential appli-
cant is applyng for as a reference when making payments). Copies of qualifying certifications/certification
counts attached
Yes! Sign me up for Automatic Renewal
Signatures
USING THE PAYMENT INFORMATION ABOVE
* Note that the application fee covers new member/membership-level Payment information included
processing. Once certified, complimentary membership benefits are
extended to the end of this calendar year. To continue your member- One photo attached
ship next year and onwards, you must renew annually.
OFFICE USE ONLY
Rec’d Code SUBMIT TO: Your PADI Regional Headquarters
Ent’d Paid For contact information, visit: [Link]
Shipped Initials
Reapplied Amount
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PRODUCT NO. 10416 (Rev. 11/23) Version 1.03 © PADI 2023
