- The box with * is required. Please fill them all.
- You may not fill "Name (Thai)" if you do not have one.
- Please use the address that we can contact or post documents to you, not necessary to be legal residence.
- In case you are not living in Thailand, please note your city in the box "Other things ..." at the bottom.
- You can easily move to the next box with the button [Tab] on your keyboard.

Name (Thai)	นายนางน.ส.ด.ช.ด.ญ.			Nickname	*
Name (Eng.)	Mr.Ms.Mrs.Miss			Birth Date
Weight	kg Heightcm Shoe size			Gender	MaleFemale*
	(Shoe size may be specified in UK or US size)
Tel.		Fax		Mobile
Address				Passport No.
City/Province	== Not in Thailand ==KrabiBangkokKarnjanaburiKalasinKamphangpetchKhonkaenChanthaburiChachoengsaoCholburiChainartChaiyaphumChumphonTrangTradTakNakhon nayokNakhon pathomNakhon phanomNakhon ratchasimaNakhon sri thammaratNakhon sawanNonthaburiNarathiwasNanBuriramPathumthaniPrachuabkirikhanPrajinburiPattaniPhranakhon sri ayuddhayaPhayaoPhang-ngaPhatthalungPijitPhitsanulokPhuketMahasarakhamMukdahanYalaYasothornRanongRayongRatchaburiRoi-edLopburiLampangLamphoonSrisaketSakolnakhonSongkhlaSatoonSamutprakarnSamutsongkhramSamutsakhonSaraburiSinghburiSuphanburiSurat-thaniSurinSukhothaiNongkhaiUdonthaniUtaraditUthaithaniUbolratchathaniAngthongChiangraiChiangmaiPetchaburiPetchaboonLoeiPhraeMaehongsonZIP Code			Best contact	E-mailMobileSMSHome Phone
E-mail	* E-mail 2

Course	Let Me TryOpen WaterAdvanced Open WaterEmergency First ResponseRescueEFR + RescueDivemaster	Want to start
Place	Soi Pattanakan 57Ekkachai - BangbonSoi Wat Rangbua BangkaeAny of these places	Availability	Mon - FriSat - SunSat OnlySun OnlyOther ...
Swimming	IncapableShort swimmingSwimmerSportsman	Familiarity w/ water	Bad experienced with waterNever been in water. Not sure about feelingEven been in water with floatableCapable to stay in water without any floatableEver been snorkeling many timesFamiliar with water and the sea

*	I understand that in the case my course does fail or take longer time and more resources due to my physical or psychological conditions, the shop may request a reasonable surcharge to me as for operate the course as fun, safe, and successful to me.
*	I have never had or been with these symtoms or diseases; - High blood pressure - Respiratory diseases - Ear problems - Spinal problems - Stroke, Heart disease - Diabetes - Sinusitis - Unconciousness from vicious impact on head or brain within the last 5 years - Incapable to do little exercises such as walking 1.6 km within 12 minutes

Dietary Spec.		Drug Allergy
Congenital Disease		Blood Type
Emergency Contact		Relationship
Address		Tel./Mobile
Personal Hospital		Tel.

Last Cert.	Non-DiverOpen WaterAdvanced Open WaterRescueMaster Scuba DiverDivemaster TraineeDivemasterOWSI Experiencedives	Last time on
Equipment	Mask Snorkel Fins Wetsuit BCD Regulator Dive Comp.
Size	BCD Wetsuit Fins2 - 33 - 43½ - 4½4 - 55 - 66½ - 7½8 - 99½ - 10½11 - 12