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 ______________________________ PRODUCT NO. 10169 (Rev. 08/13) Version 2.12 © PADI 2013.

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