Note: Fill out this form and then print it on your printer. Send the form and payment to the certification agency (Not High Sierra Divers)

---

PADI LOST CARD REPLACEMENT FORM
1251 East Dyer Road, #100 . Santa Ana, CA 92705-5605 . (714) 540-7234 Telex 678400 PADIINT SNA . FAX (714) 540-2609 . Cable PADI\NTL CO VIA WUW

---

This form is to be used when requesting replacement of a lost PADI certification card. Please read all directions carefully and be certain that all requested Information/materials are enclosed. If information/materials are missing or incomplete, it will cause slower processing or the return of all submitted materials. Please enclose one 11/4 " x 13/4" photograph of yourself to be used on your certification card. This picture is for the purpose of identification. Be sure to submit a clear, unobstructed photograph. The current replacement fee is $20. Please make your check or money order payable to PADI. We suggest you do not send cash through the mail. Once again, use this form only if you are requesting the replacement of a certification card that was lost, stolen or destroyed. If you never received your initial certification card, please contact either your PADI Instructor, Training facility or PADI Headquarters to obtain the proper form.

---

Section 1 - Please print or type

Return card to Training Facility Instructor Student

Student Number

Instructor Name	Instructor #
Training Facility	Facility #
Date of Certification	Cert. Level

Student Name

Mailing Address

City	State

Country	ZIP

Phone

Date of Birth

Sex Male Female

If you are requesting that your name be changed on your new certification card, please include a copy of the legal documentation of name change (marriage certificate, etc.)

Section 2

If your certification card was issued after 1980, you should have received a PADI Validation Card with your permanent certification card. If you still have your PADI Validation Card, please enclose a copy of it with this form. If you supply a copy of the Validation Card, you do not need to complete section 2 of this form.

Your address at the time of your certification (including city, state/province and country)

When did you receive your certification card? month/year

(If you are not sure of the exact date, please approximate.)

Course Completion Date

Have you ever had your "C-Card" replaced

No Yes

If yes, in what year?

If replaced in 1980 or later-list student number

Requested Replacement Card Skin Diver Junior Basic Diver Basic Diver Junior Open Water Diver Open Water Diver Advanced Open Water Diver Rescue Diver Divemaster Specialty _____________________________________ Other _________________________________________

---

PHOTO Attach Here Head-and-shoulders 1-1/4" X 1- 3/4" Coin Machine Ok No Sunglasses

---

PLEASE READ CAREFULLY

Though this section is not required, its completion is highly recommended; this additional information will speed the replacement of your certification card. If you are easily able to contact your original Instructor/Training Facility and they will provide verification of your scuba certification, please have them complete the appropriate section below. Please be sure that all requested information is provided and original certification information is used.

TO BE USED BY ORIGINAL CERTIFYING INSTRUCTOR ONLY

Instructor Name		Instructor #
Training Facility		Training Facility #
Level of Certification		Date of Certification

---

TO BE USED BY ORIGINAL TRAINING FACILITY/DIVE STORE ONLY

If the certifying Instructor is no longer with the Training Facility/dive store, either the facility owner, manager or another PAD I Instructor (of the original store) may verify the student's certification. The verifying person must attest that the original student records are on file with the Training Facility/dive store, as PADI may request that such records be supplied.

Instructor Name	Instructor #
Level of Certification	Date of Certification
Training Facility	Verifying Individual's Name (Please print)
Verifying Individuals Title	Verifying Individual's Signature

---

Other acceptable forms of verification are listed below. You may submit a copy of anyone of these forms of verification with this form (please do not send the original). This will aid in reducing the processing time of your replacement certification card.

a. A signed and dated PADI Temporary certification card.
b. A signed letter from the certifying Instructor/Training Facility. This letter must include the date and level of certification, the PAD I Instructor's name, and his Instructor number.
c. A copy of a signed PADI diploma.
d. A copy of your original certification envelope.
e. A copy of both sides of your original certification card.

Please allow 5-6 weeks for the processing of your card. Should additional information be necessary, or a problem arise, you will be notified as soon as possible.

---

In order to expedite the processing of your PADI certification card these materials must be returned with this form.

Payment Replace Card - $ 25 48 Hour Replace Card $ 35

Type of Payment Visa Master Card Check Money Order

Credit Card Number

Expiration Date mm/yy

Cardholder Name

Cardholder Signature

---

CHECK LIST

Processing Fee

Photograph

Photocopy of Validation card, Temp Card or Wall Certificate