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)

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Current Name (or send copy of legal change)

Course Level - Scuba, Advanced, Etc.

Instructor #

Course Date mm/yy

Instructor Name

Facility Name

Pin #, Reg # or SS#

Age when certified

Name when Certified.

City & State Certified.

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Payment Replace Card - $ 25 Next Day - $ 50 2nd Day - $ 47 Fax Verify Only - $ 15 Fax Verify & Card - $ 62

Type of Payment Visa Master Card Am Express Check Money Order

Credit Card Number

Expiration Date mm/yy

Cardholder Name
Cardholder Signature

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Ship to Name

Phone Number

FAX Number

Mail Address
City, State, Zip

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I do hereby swear under penalty of perjury, that I am at least 18 years of age, that I was issued a SDI/TDI certification card as indicated above on or about the date indicated above. I further state that I have lost the card which was issued and after a thorough search, can find no other information except that provided above to substantiate this affidavit. I hereby release SDI/TDI, its members, directors, and officers from any and all liability that may arise as a result of accepting, as true , this affidavit and issuing a replacement card.

Signature

Date