| DIVERSION
DIVE TRAVEL |
Diver
Profile
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Please
fill in the following questions thoroughly. The information
will only be shared with the operator with the aim to make
your trip as enjoyable, safe and comfortable as possible.
Please fill in one form per participant, print it out
and fax it to
+61 740 390 300
(replace "+" with the int. prefix
required in your country. e.g. from USA 011 61 740
390 300)
or mail to: DIVERSION DIVE TRAVEL, PO BOX 191, Redlynch
QLD 4870
AUSTRALIA
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1.
Please select the Dive Cruise
you have booked with us:
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date
of cruise:
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in
Australia:
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in
Papua New Guinea:
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in
Micronesia:
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in
Solomon Islands:
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in
Fiji::
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in
SouthEast Asia:
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| Full
name: |
as shown in Passport |
your
Email:
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Country:
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Address
Line1: |
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Address
Line2:
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| City:
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Phone:
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Post
Code:
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Fax: |
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| 3.
Dive Information: |
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Date
of Birth:
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/
/
dd / mm
/ yyyy
25/12/1975 = December 25, 1975
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Height:
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cm
or ft/in |
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Weight
:
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kg
or lb |
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Dive
Experience:
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certification
Agency
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No.
of dives:
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| Certification
Level
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date
of last dive:
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Dive
Insurance:
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Please
name your Scuba Diving Insurance:
If you do not have a dive insurance, we recommend
a membership with the DIVERS ALERT NETWORK (DAN) for more information,
please check the insurance
section. |
Equipment
hire Prices
for hire gear vary with companies and duration of the trip. You find
the cost on the respective webpages.
Do you want to hire dive gear?
Yes
No
Please check items and sizes required |
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BCD
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Regulator
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Wetsuit
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Mask/Fins/Snorkel
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Boots sizes
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Dive computer
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Torch
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Nitrox**
do you want to use Nitrox?
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**only
available on the following boats:
in Australia: All
boats in
SouthEast Asia: All
boats except Dive Komodo
in PNG: Golden Dawn,
Telita, Soirit of Niugini, Star Dancer, Febrina
in Micronesia and Solomons: All
boats in
Fiji:
All
boats |
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4.
Emergency Contacts /Medical Information:
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In
case of Emergency Contact:
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Email:
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Country:
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Address
Line1: |
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Address
Line2:
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| City:
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Phone:
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Post
Code:
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Fax: |
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Relation:
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| Medical
Statement: |
Are
you medically & physically fit to dive ?
yes
no |
Medical
Conditions:
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Do
you have any medical conditions (history/allergies/handicaps, etc.)
that we should be aware of? If yes, please give details.
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Prescription
Medicine:
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Do
you take any medication that we should be aware of?
If so, please give details.
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| personal
doctor contact: |
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5.
Please let us know your special requirements :
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Dietary
requirements:
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Do you have any special dietary requirements?
(allergies, vegetarian,etc.)
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Other
requirements/ comments:
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Do you have any other special requirements, wishes, comments that we
should know about?
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| Signature |
_____________________________________
date ____/____/____ |
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