Blue Moon Dive Club   

APPLICATION for MEMBERSHIP to the

BLUE MOON Dive Club

MEMBERSHIP IN THE BLUE MOON Dive Club, IS OPEN TO ANYONE INDICATING A WILLINGNESS TO LEARN AND ABIDE BY THE CLUB’S CONSTITUTION, BY-LAWS, SAFETY STANDARDS AN!) WHO IS SPONSORED BY A CLUB MEMBER IN GOOD STANDING.

 NAME _________________________________ AGE _____

 ADDRESS _______________________ CITY _____________ ST ZIP ____

 HOME # ______________ WORK # ______________ MARITAL STATUS _____

 E-MAIL ADDRESS ___________________________

 SPONSOR’S NAME _________________________

 TYPE OF MEMBERSHIP DESIRED:   INDIVIDUAL_____ FAMILY/DEPENDENTS____

 NUMBER OF FAMILY MEMBERS (Family Membership Only) _____

 NAMES OF FAMILY MEMBERS _______________________________________

 HOW DID YOU LEARN ABOUT THE CLUB? __________________________________

  
CERTIFIED DIVER (Y/N) FAMILY MEMBERS (If Appropriate) (Y/N)

IF NO, DO YOU SEEK TO BECOME CERTIFIED THROUGH THE CLUB?

IF YES, ARE YOU INTERESTED IN UPGRADING OR TAKING SPECIALTY COURSES? —

LEVEL/TYPE OF CERTIFICATION (Circle One): Basic Advance Master

 DATE CERTIFIED _________ CERTIFYING AGENCY ___________

HOW MANY DIVES HAVE YOU MADE IN THE LAST 12 MONTHS? ___

WHAT TYPE OF DIVES WERE MADE IN THE LAST 12 MONTHS? (ocean, wreck, reef springs, cavern, etc.)

DIVING SPECIALTIES OR AREAS OF INTEREST? (collecting, photography, exploration, etc.)