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DSD Internship Completion Form

This document provides the completion form for the PADI Divemaster Discover Scuba Diving internship. It details the requirements to complete four Discover Scuba Diving programs under supervision and submit the signed form for authorization to conduct the programs independently. The form requests applicant information and internship details to be verified by the supervising instructor.

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Terence
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455 views1 page

DSD Internship Completion Form

This document provides the completion form for the PADI Divemaster Discover Scuba Diving internship. It details the requirements to complete four Discover Scuba Diving programs under supervision and submit the signed form for authorization to conduct the programs independently. The form requests applicant information and internship details to be verified by the supervising instructor.

Uploaded by

Terence
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PADI DIVEMASTER

Discover Scuba Diving Internship Completion Form


PADI Divemasters in Active Status (and with insurance, where required) may conduct PADI Discover Scuba Diving
programs in a pool or confined open water environment after successfully completing a Discover Scuba Diving
internship. The internship consists of conducting four separate PADI Discover Scuba Diving programs in a pool or
confined open water environment under the direct supervision of a PADI Instructor. After completing the internship,
submit this form, signed by the instructor, to your PADI Office for processing and authorization.

PLEASE PRINT CLEARLY

Check here if this is a change of address and you want our records changed accordingly.

Name __________________________________________________________________________________________ PADI No. ________________


First

Initial

Last

Mailing Address __________________________________________________________________________________________________________


City ________________________________________________________________ State/Province ______________________________________
Country ___________________________________________________________________________ Zip/Postal Code ______________________
Home Phone (_____)______________________________________ Business Phone (_____)__________________________________________
FAX (_____)_____________________________________________ Email _________________________________________________________
Date of Birth _______________________

Sex:

Preferred Language _______________________________________

D/M/Y

INTERNSHIP VERIFICATION PADI DISCOVER SCUBA DIVING PROGRAMS


Date_______________ Supervising Instructor _____________________________________________ PADI Number ______________
Date_______________ Supervising Instructor _____________________________________________ PADI Number ______________
Date_______________ Supervising Instructor _____________________________________________ PADI Number ______________
Date_______________ Supervising Instructor _____________________________________________ PADI Number ______________

 Completed Discover Scuba Diving Leader Internship Assessment


I verify that this PADI Divemaster has completed four required Discover Scuba Diving programs and scored at least 3 on each
performance requirement under the direct supervision of a PADI Instructor
Verifying Instructor ________________________________________________ PADI No.___________________ Date ______________
Verifying Instructor Signature

D/M/Y

PAYMENT METHOD

CARD OPTIONS

See current price list for payment information.


 MasterCard
 VISA
 American Express
 Discover Card
 JCB
 Maestro/Solo (UK only)
 Check/Bank Draft No.* ______________________________

PADI Standard Card (additional fee)


No card required
Support conservation with your Project AWARE Foundation version of
the PADI Card:
Project AWARE Foundation Card
_________
(Please indicate the amount of your donation.
For a minimum required for processing, please
contact your PADI Office)

*Check/Bank Draft must be payable in the currency of the PADI Office the
application is submitted to.

Card Number __________ __________ __________ __________


Card expiration date _____________________________________
Maestro/Solo valid from date ______ or Issue No. _____(UK only)
Cardholder Name _______________________________________
Please Print

Authorized Signature ____________________________________

MAIL TO: Your PADI Office


Attn. Divemaster Certification
For mailing information, see current
price list or visit padi.com.

Recd ______________________________
PRODUCT NO. 10151 (7/09) Version 1.04

CHECKLIST
Application completed in full
Applicant and instructor signatures
One photo attached
(Include only if requesting a
replacement certification card.)
See price list for fee (Fee includes
a quarterly subscription to The
Undersea Journal valued at $12 or
equivalent in local currency.)

Tape / Attach a
4.5 cm x 5.7 cm
134" x 214" (approx.)
Head and Shoulder Photo

PRINT NAME ON
BACK OF PHOTO
Coin Machine Photos OK
No Dark Glasses

Entr'd ______________________________

Shpd __________________________________
PADI 2009

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