ODU-Diver-Application-Form.doc - Old Dominion University Academic Diving Program Diver Certification Application Name Date Age Birth Date Local Address

Old Dominion University Academic Diving Program Diver Certification Application Name: _________________________________________ Date: ___________________ Age: ___________ Birth Date: _____________________ Local Address:___________________________________________________________ Permanent Address (if different): ________________________________________________________________________ Home Phone: ( _____)________ _______ Cell phone: (_____)____________________ Business Phone: ( _____)___________________ E-Mail:_________________________________________ In case of emergency notify: ______________________ Phone: (____)_____________ Your Doctor: _________________________________ Phone: (____)______________ Address:________________________________________________________________ Date Of Most Recent Medical Examination: __________________________________ Previous Diving Related Certification or Experience : (Use back of form if needed) Certification/Organization Date Location _______________________________ ___________ _________________________ _______________________________ ___________ _________________________ _______________________________ ___________ _________________________ _______________________________ ___________ _________________________