TAT License No. 12/01654
Scuba Diving Course Application Form
- 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.

Personal Information

Name (Thai) Nickname *
Name (Eng.) Birth Date
Weight kg Heightcm Shoe size Gender *
(Shoe size may be specified in UK or US size)
Tel. Fax Mobile
Address Citizen ID. *
City/Province ZIP Code Best contact
E-mail * E-mail 2

Course Arrangement Information

Course Want to start
Place Availability
Swimming Familiarity w/ water
*
*
- 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

Health Information

Dietary Spec. (e.g. Not spicy) Drug Allergy
Congenital Disease Blood Type
Emergency Contact Relationship
Address Tel./Mobile
Personal Hospital Tel.

Diving Information

Last Cert. Experiencedives Last time on
Equipment
Size BCD Wetsuit Fins
Other things you want us to know