DIVEMASTER OFFICE USE ONLY
# - ____________________________
APPLICATION Cert. Date ______________________
By ____________________________
PLEASE PRINT CLEARLY Return certification package to: Dive Center/Resort Instructor Applicant
Name __________________________________________________________________________________________________________________
First Initial Last
Mailing Address __________________________________________________________________________________________________________
City ________________________________________________________________ State/Province ______________________________________
Country ___________________________________________________________________________ Zip/Postal Code ______________________
Home Phone (_____)______________________________________ Business Phone (_____)__________________________________________
FAX (_____)__________________________ Email ___________________________________________________ Date of Birth _______________
D/M/Y
Sex: M F Preferred Language _____________________ Where will you work after certification ___________________________________
Country
PREREQUISITE REQUIREMENTS
Must be PADI Advanced Open Water Diver, PADI Rescue Diver and Emergency First Response Primary Care (CPR) and Secondary Care (First Aid),
or hold qualifying certifications from another organization. Copies of ALL non-PADI certifications must be attached to this application.
PADI AOW _____________________________ PADI Rescue ________________________________ EFR ______________________________
Student Number Student Number Student Number
DIVEMASTER CERTIFICATION INFORMATION
This Application must be signed by the applicant and the certifying instructor (a PADI Open Water Scuba Instructor or higher level). This
application does not constitute membership. Membership is activated only upon review and approval of this application by PADI.
PADI Divemaster Course Completion Date ________________ Course Location ____________________________________________________
D/M/Y City/State/Province/Country
Certifying Instructor Name ________________________________________________________ Phone (_____)____________________________
Dive Center/Resort Name ____________________________________ Store No. ___________ Phone (_____)___________________________
I have read the Membership Agreement,* and License Agreement,* 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.
Applicant’s Signature ________________________________________________________________ Date ________________________________
Signature — Required D/M/Y
I certify that all prerequisites and certification requirements have been met as outlined in the PADI Instructor Manual.
Certifying Instructor _________________________________________________________ PADI No. _______________ Date ________________
Signature — Required D/M/Y
I verify the applicant has logged 60 dives. Initials of verifying instructor _____________ PADI No. _____________
*Agreements are found in Divemaster Crew-pak or may be obtained from your instructor.
PRODUCT NO. 10144 (07/13) Version 4.09 page 1 of 2 © PADI 2013
PAYMENT METHOD CARD OPTIONS
See current price list for payment information. PADI Standard Card (no additional fee)
MasterCard VISA American Express
Support conservation with your Project AWARE version of the PADI
Discover Card JCB Card:
Check/Bank Draft No.* ________________________________
Project AWARE Card _________
*Check/Bank Draft must be payable in the currency of the PADI Office (Please indicate the amount of your donation.
the application is submitted to. For a minimum required for processing, please
contact your PADI Office)
Card Number __________ __________ __________ __________
Card expiration date ____________________________________ PLEASE DO NOT WRITE IN THIS SPACE
Cardholder Name ______________________________________ Date ____________________________
Please Print
Amount _________________________
Authorized Signature ___________________________________
CHECKLIST MAIL TO: Your PADI Office
Attn. Divemaster Certification Tape / Attach a
Application completed in full
For mailing information, see current 4.5 cm x 5.7 cm
Prerequisite information completed and required price list or visit padi.com.
documentation attached 13⁄4" x 21⁄4" (approx.)
Applicant and instructor signatures Head and Shoulder Photo
One photo attached (print name on back)
PRINT NAME ON
BACK OF PHOTO
Coin Machine Photos OK
No Dark Glasses
Place decal from
Instructor Manual
HERE
Rec’d ______________________________ Ent ______________________________ Shp’d ______________________________
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