BURLINGTON SCUBA
189 Cambridge Street
Burlington, MA 01803
781-272-5164
ONLINE DIVE CLUB MEMBERSHIP FORM
[Print and fill out this form. Mail or bring it to Burlington SCUBA with your membership fee]
NAME:______________________________________________________________
ADDRESS:___________________________________________________________
(STREET, CITY, STATE, & ZIP)
PHONE (H):___________________(W)_________________(C)________________
EMAIL:______________________________________________________________
DATE OF CERTIFICATION:____/____/____
LEVEL(circle one): Open Water | Advanced Open Water | DiveCon
APPROX. NUMBER OF LOGGED DIVES:_________________________________
NUMBER OF DAYTIME DIVES_______________NIGHT DIVES______________
1. Do you own or rent your dive equipment?__________________________________
2. Are you interested in night diving?________________________________________
3. Would you like to further your dive education?______________________________
4. Are you interested in dive trips to exotic places?_____________________________
DIVE CLUB MEMBERSHIP FEE FOR 2007 IS $80.00
Signature____________________________________________Date:____/____/____