Full Name:       Date of Birth:        Age:

Street: City: State: Zip Code:

Gender: Male     Female            Vegetarian: Yes     No

E-mail address:

Day phone:             Evening phone:

Citizenship:

Passport No:

Date issued: Where: Expiration date:

Medical Information

Do you have any medical conditions, history or physical impairments that can make diving or other underwater activity dangerous to you or others?:     Yes      No

If yes, please specify:

Physician's Name: Phone:

Street address: City: State: Zipcode:

Diving Experience

Years diving:     Main Diving Interests:

Previous Dive Experience:

Diving ability: Beginner     Intermediate     Advanced     Expert

General Information

Airline seat preference: Window     Aisle

Special Dietary Requests: Date:

Airport Departure: Departure Date:

Emergency Contact (Mandatory per USDOT rules effective Jan. 1, 2003)

Contact Name: Contact Phone:

Comments & Requests: