Section A: To be completed by all applicants.

First Name:
Middle Name:
Last Name:
Address:
City:
State and/or Province:
Country:
Zip or Postal Code:

Home Phone #:
Work Phone #:
Fax #:
Email Address:

I.A.N.T.D. Cert.:	/
Open Water Cert.:	/	/

Section B: Instructors and Owners. Only complete if your facility
has a public Nitrox or Trimix fill station.

 Nitrox
 Trimix

Facility Name: 		
Address:       		
City:          		
State and/or Province:  
Country:		

Zip or Postal Code:     
Home Phone #:  		
Work Phone #: 		
Fax #:         		
Email Address: 		

Section C: All Applicants. Please complete this section(optional). A summary
will be published twice a year.

1 General Information

2 Diving Profile

3 Diving and safety practices

Do you practice basic survival skills (Equipment handling, gas sharing, etc.)?
Yes
 No
Do you classify yourself as a Safe Diver?
 Yes
 No
Have you ever been been in an out of air/gas situation?
 Yes
 No
If YES, how many times?

Have you assisted another diver who was out of air/gas?
 Yes
 No
If YES, how many times?

Do you practice the rule of thirds when diving below 100 fsw(30 msw),
on wreck penetration dives, on decompression dives, and/or
when cave diving?
 Yes
 No
If NO what rules do you follow?
 1/2 + 200 psig (14 bar)
 Play it by ear
 None

Do you support buddy system diving?
 Yes
 No
What percent of the time do you solo dive?

4 Travel and future training

Do you take dive travel vacations?
 Yes
 No
Your favorite location is?

Why?

Your least liked location is?

Why?

Would you support dive destinations that cater to technical diving?
 Yes
 No
If available, would you take Technical Diver Training at resorts?
 Yes
 No
What programs are you interested in?

Section D: Back Issues and Payments.

Membership in IANTD includes one year subscription to the IANTD's Nitrox Dive Magizine,
which is published four times a year.

Available Back Issues - Volume #'s: (Check box for Volume # requested)
92-1
93-1
93-2
93-3
93-4
94-1
94-2
94-3
94-4
95-1
95-2
95-3
95-4
96-1
96-2
96-3
96-4
97-1
97-2

Other: 

Check annual fee that will apply to you:
$40 USA
$50 Out of USA
Back Issues Ordered @ $10, Member Back Issues Ordered @ $5

Type of payment method you will be using:
MC
VISA
CHECK