Assistant Instructor Application

ASSISTANT INSTRUCTOR

APPLICATION

PREREQUISITES –

PADI Divemaster certiﬁcation or leadership-level certiﬁcation from another recreational diver training organization is

required as a prerequisite to the Assistant Instructor rating. Please complete the information below or submit proof of leadership-level certiﬁcation as

speciﬁed in the “Assistant Instructor Course Guide.”*

Divemaster Number__ __________________________ Divemaster Certification Date __ ________________________

D/M/Y

Instructor Name __ __________________________________________________ ______________________________ PADI No. _______________

*If submitting proof of leadership-level certification, attach photocopies of prerequisite certifications and proof of CPR and first aid training.

CERTIFICATION INFORMATION

This Application must be signed by the applicant and the certifying instructor (a PADI Course Director or IDC Staff Instructor).

PADI Assistant Instructor Course Completion Date ________________ Course Location _______________________________________________

D/M/Y City/State/Province/Country

Certifying Instructor Name ______________________________________________________ Phone (_____)______________________________

Dive Center/Resort Name ____________________________________ Store No. ________ Phone (_____)______________________________

I have read the PADI Membership Agreement,* and License Agreement,* and hereby consent and agree to the terms and conditions in their entirety. I understand and

agree that any criminal conviction on my part involving abuse of a minor or sexual abuse of an adult occurring either during or prior to my membership with PADI, will

be automatic grounds for denial or termination of my PADI Membership. I hereby certify that all the above statements are true and correct to the best of my knowledge.

Applicant’s Signature __________________________________________________________________ Date ______________________________

Signature — Required D/M/Y

I certify that all prerequisites and certiﬁcation requirements have been met as outlined in the PADI Course Director Manual.

Certifying Instructor _________________________________________________________ PADI No. _______________ Date ________________

Signature D/M/Y

MEDICAL FORM –

A current medical examination form must be submitted to your instructor before beginning the Assistant Instructor course. The form

must verify that you are physically fit for diving, be signed and dated by a physician, and be submitted within 12 months of the examination. (PADI Divemasters

who have a medical exam form on file with the instructor within the 12-month

limit need not submit a new examination unless medical history has changed.)

PRODUCT NO. 10152 (Rev. 07/13) Version 2.11 © PADI 2013

Tape / Attach a

4.5 cm x 5.7 cm

⁄

" x 2

⁄

" (approx.)

Head and Shoulder Photo

PRINT NAME ON

BACK OF PHOTO

Coin Machine Photos OK

No Dark Glasses

MAIL TO:

Your PADI Office –

For mailing information, see current price list or visit padi.com. Rec’d _________ Entr’d _________ Shp’d _______

OFFICE USE ONLY

# - ____________________________

Cert. Date ______________________

By ____________________________

PLEASE PRINT CLEARLY

Return certification package to: Dive Center/Resort Instructor Applicant

Check here if this is a change of address and you want our records changed accordingly.

Name __________________________________________________________________________________________________________________

First Initial Last

Mailing Address __________________________________________________________________________________________________________

City ________________________________________________________________ State/Province ______________________________________

Country ____________________________ Zip/Postal Code ________________ Preferred Language ____________________________________

Home Phone (_____)______________________________________ Business Phone (_____)__________________________________________

FAX (_____)_______________________ Email _______________________________ Date of Birth _____________ Sex:

M F

D/M/Y

PLEASE DO NOT WRITE IN THIS SPACE

Date ____________________________

Amount _________________________

CHECKLIST

Application completed in full

Prerequisite information completed and

required documentation attached

Applicant and instructor signatures

Instructor Candidate Information and

Training Record form attached

Instructor Candidate Information and

Training Record form attached

Medical exam form (on file with instructor)

Photo attached (print name on back)

See price list for fee)

CARD OPTIONS

PADI Standard Card (no additional fee)

Project AWARE Card (Please indicate

the amount of your donation. For a

minimum required for processing,

please contact your PADI Office)

______________________

PAYMENT METHOD

See current price list for payment information.

 MasterCard  VISA  American Express

 Discover Card  JCB

 Check/Bank Draft No.* ______________________________

*Check/Bank Draft

must be payable in the currency of the PADI Office the

application is submitted to.

Card Number _________ __________ __________ __________

Card expiration date ___________________________________

Cardholder Name ______________________________________

Please Print

Authorized Signature ___________________________________