Master Scuba Diver Trainer Application

OFFICE USE ONLY MASTER SCUBA DIVER # - ______Cert. Date ______

TRAINER APPLICATION By ______

For use by PADI Open Water Scuba Instructors. The MASTER SCUBA DIVER TRAINER rating is awarded to Open Water Scuba Instructors who are certified in five or more PADI Specialty Instructor ratings and who have certified at least 25 PADI divers. PLEASE PRINT CLEARLY Check here if this is a change of address and you want our records changed accordingly.

Name ______PADI No. ______First Initial Last Mailing Address ______City ______State/Province ______Country ______Zip/Postal Code ______Home Phone (_____)______Business Phone (_____)______FAX (_____)______Email ______PADI INSTRUCTOR SPECIALTY CERTIFICATIONS HELD

Altitude Diver Distinctive Specialty Dry Suit Diver Multilevel Diver Public Safety Diver Atlantis/Dolphin Rebreather Deep Diver Enriched Air U/W Naturalist Ray Rebreather AWARE Fish ID Digital U/W Photographer Emergency Oxygen Provider U/W Navigator Search & Recovery Dive Boat Diver Diver Propulsion Vehicle Equipment Specialist Night Diver Sidemount Diver Cavern Diver Drift Diver Ice Diver U/W Photographer Underwater Videographer Wreck Diver Title(s) ______

I certify that the information contained here is true and correct to the best of my knowledge and understand that this certification is subject to the approval of PADI.

______Date ______Signature D/M/Y PAYMENT METHOD CHECKLIST See current price list for payment information. Application completed in Tape / Attach a  MasterCard  VISA  American Express full and signed 4.5 cm x 5.7 cm  Discover Card  JCB One photo attached (print 13⁄ " x 21⁄ " (approx.) name on back) 4 4  Check/Bank Draft No.* ______Head and Shoulder Photo See price list for fee *Check/Bank Draft must be payable in the currency of the PADI Office PRINT NAME ON the application is submitted to. BACK OF PHOTO Card Number ______Coin Machine Photos OK Card expiration date ______No Dark Glasses Cardholder Name ______Please Print MAIL TO: Your PADI Office For mailing information, see Authorized Signature ______current price list or visit padi.com. CARD OPTIONS PADI Standard Card (no additional fee) Support conservation with your Project AWARE version of the PADI Card: PLEASE DO NOT WRITE IN THIS SPACE

Project AWARE Card ______Date ______(Please indicate the amount of your donation. For a minimum required for processing, please contact your PADI Office) Amount ______

Rec’d ______Entr'd ______Shp’d ______