Please print out form and send to Phil or Bill.

Legal Name __________________________________________________________________________________

Birthdate __________________________________________________       U.S. Citizen?   YES     NO

Address __________________________________________  City _____________________  State ________

Telephone Home __________________________________  Telephone Work ____________________________ 

FAX ___________________________  e-mail ______________________________________________________

Rooming With _________________________________________________________________________________

Passport Number ______________________________________________ Expiration ____________________

Are you a certified diver?   YES   NO 

Certification Agency and Number ______________________________________________________________

Number of Dives __________________________________
Number of Dives in the past year ______________________________
Date of Last Dive __________________________________

DAN Insurance Required! (or similar diver accident insurance coverage)  YES   NO
DAN Insurance Number ____________________________________________________
Would you like to arrange monthly payments?  YES   NO

Emergency Contact Not Traveling With You:
Name _________________________________________________________Relationship __________________
Telephone _______________________________________________________

Omni Divers Underwater Services, L.L.C. and Omni Travel Adventures arranges for your travel services with reputable hotel, airline and other independent suppliers who provide the service you purchase. However, Omni Divers Underwater Services, L.L.C. and Omni Travel Adventures does not have direct control over them; therefore Omni Divers Underwater Services, L.L.C. and Omni Travel Adventures, its directors, agents and employees assume no responsibility or liability for the weather, services, transportation or equipment made available or as to its safety, quality or condition, nor for acts of any employee or agent of any establishment, firm, person or entity furnishing such service, transportation or equipment. Nor does Omni Divers Underwater Services, L.L.C. and Omni Travel Adventures, its directors, agents and employees assume any responsibility or liability for the safety of any participating client engaged in water activities above or below the water. We are committed to your satisfaction and thank you for your business and cooperation.

Signature ___________________________________________________ Date _________________________

Deposit Date ___________________
Amount: ___________ Credit Card MC/V ______________________________ Cash ___ Check No. _____

Payment Date ___________________
Amount: ___________ Credit Card MC/V ______________________________ Cash ___ Check No. _____

Payment Date ___________________
Amount: ___________ Credit Card MC/V ______________________________ Cash ___ Check No. _____

Payment Date ___________________
Amount: ___________ Credit Card MC/V ______________________________ Cash ___ Check No. _____

Payment Date ___________________
Amount: ___________ Credit Card MC/V ______________________________ Cash ___ Check No. _____

Trip Brochure ______________________________________________
Trip Insurance Brochure ____________________________________
DAN Insurance Brochure _____________________________________