Last Name _________________ First Name ______________ M.I. __ Nick Name ________DSM96Address: ________________________________________________________________ Street City State _____________________________________________ (____)_______-_______ Country Zip code Telephone
My Email Address is: ________________________________________________
DOB _______ Sex: M F SSN _______________ Medication Taken ________________
Medical Insurance Carrier________________________________ No.___________________
Is this Short Term Insurance? Yes / No If Yes, when does this policy expire? _________
DAN Insurance No. _________________
Allergies _____________ Blood Type____ Other Emergency/Medical Information _________________
_____________________________________________________________________________________________
Dept. ________ Classification: Fr. So. Jr. Sr. Grad. Fac. Staff Visiting Scientist Volunteer
Emergency Contact Information:
Name ___________________ Phone ________________HOME _______________WORK
Relationship _________________Address __________________________________________
( ) I have personal SCUBA equipment (regulator, BC, gauges) for use during training. Date of last regulator maintenance: ____________ (Proof of maintenance required)
( ) I do not currently own personal SCUBA equipment.
APPLICATION IS FOR: (circle one) Scientific Diver or Temporary Diving Permit
I will be involved in: ( ) Course Work at ECU: Department / Program ________________________ ( ) A Research Project at ECU: Dates________________ Scientific Supervisor _________________ ( ) Other:(please specify) _____________________________________________________________
CIRCLE ANY OF THE FOLLOWING COURSES COMPLETED. (submit copies of c-cards with application)
1. Open Water or Basic SCUBA. Date of certification ______________ Agency ____________ 2. NAUI / PADI Advanced or equiv. 3. NAUI Master Diver/ PADI Advanced Plus or equiv. 4. Dive Rescue 5. Assistant Instructor: agency_________ 6. Divemaster: agency ________ 7. Instructor: agency ________ 8. First Aid. Date certified _____________ 9. CPR. Date certified _____________ 10. Oxygen Administration. Date Certified ______________
Other training Info.: _________________________________________________________________
Number of Dives Logged:__________Total Bottom Time:__________
___________ Date ________________________________________________________ Signature of Applicant (Signifies that the above information is true and correct)