On-Line Membership Application Form

International Association of Nitrox and Technical Divers
2124 NE 123 Street, Suite 210, Miami, FL 33181-2939 USA
Tel: 786-704-9722 or Fax: 509-355-1297 Magazine@iantd.com

Please fill and complete ALL fields.
Note: Use "TAB" key and/or pointer to move between fields.

Section A: To be completed by all applicants:

Today's Date: //

Title: Mr. Mrs. Ms. Other

First Name:

Middle Name:

Last Name:

Street Address:

Address (cont.):

City:

State/Province:

Zip/Postal Code:

Country:

Work Phone:

Home Phone:

FAX:

E-mail:

Sex: Male Female

Date of Birth: //

IANTD. Cert.: /

Open Water Cert.: //

Section B: Instructors and Owners. Complete only if your facility has a public Nitrox or Trimix station.

Facility Type:	Nitrox Trimix
Facility Name:
Address:
Address (con't.):
City:
State/Province:
Zip/Postal Code:
Country:
Work Phone:
Home Phone:
FAX:
E-mail:

Section C: All applicants. Please complete this section (optional).

1. General Information:

Years of Diving Experience:

List advanced training programs completed:

2. Diving Profile:

# of Dives 10-30 fsw (3-9 msw):
# of Dives 30-60 fsw (9-18 msw):
# of Dives 60-90 fsw (18-27 msw):
# of Dives 90-130 fsw (27-40 msw):
# of Dives 130-160 fsw (40-49 msw):
# of Dives 160-190 fsw (49-58 msw):
# of Dives 190+ fsw (58+ msw):

Total # of Dives:
# of Trimix Dives:
Deepest Dive:
# of Cave Dives:
# of EANx Dives:
# of Wreck Penetration Dives:
# of Wall Dives:

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 in an out of air/gas situation?
Yes
No

If yes, how many times?:

Have you ever 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 practice?
1/2 + 200 psig (14 bar)
Play it by ear
None

Do you support buddy system diving?
Yes
No

What percentage of the time do you solo dive?: %

4. Travel and Future Training:

Do you take dive travel vacations?
Yes
No

What is your favorite location?

In a few words, why?

What is your least liked location?

In a few words, 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 a one year subscription to the
IANTD's Nitrox Diver Magazine which is published three times a year.

Available Back Issues - Volume #s
(Check box for Volume #s requested)

92-1	93-1	94-1	95-1	96-1	97-1
	93-2	94-2	95-2	96-2	97-2
	93-3	94-3	95-3	96-3
	93-4	94-4	95-4	96-4

Check annual fee that will apply to you:
$25 USA
$40 Outside of USA
Back Issues ordered @ $10, Member Back Issues ordered @ $5

Check type of payment method you will be using:
Mastercard
Visa
Check - Please print application and mail with your US dollars US Bank check. Thank you.

Credit Card Expiration Date:	/
Credit Card Number:
Full Name as it appears on Credit Card:

Additional Comments and/or Information:

Today's Date:	//
Title:	Mr. Mrs. Ms. Other
First Name:
Middle Name:
Last Name:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
Country:
Work Phone:
Home Phone:
FAX:
E-mail:
Sex:	Male Female
Date of Birth:	//
IANTD. Cert.:	/
Open Water Cert.:	//

On-Line Membership Application Form

Copyright � 1996 - 2011 IAND, Inc. DBA IANTD All rights reserved. Last revised: January 17, 2011

Copyright � 1996 - 2011 IAND, Inc. DBA IANTD All rights reserved.

Last revised: January 17, 2011