Membership Application Form

Please fill in this form and post it to :

Horsea Island Dive Centre, West Bund Road, Port Solent, Cosham, Portsmouth, Hampshire, PO6 4TT

Please complete this form in BLOCK CAPITALS and use a separate form for each applicant

Surname: Title:

First Name :

Address:

 

Post Code:

Telephone Day Telephone Evening E-Mail Address
     

Current Certification
Body: Level:

Payment Method:      (Please delete as appropriate)

Credit Card (Visa, Mastercard, Access) / Cheque / Cash


CREDIT CARD
Please debit my credit card with £____________ for one years membership.
Card Number        -               -               -                SEC Code  
Signature   Expiry Date       /      /      

CHEQUES: Please make cheques payable to "Horsea Island Centre Limited"

CASH: By registered mail or directly to the booking office on site.

SENDER'S CHECKLIST
Please ensure you enclose the following :
  • Completed application form.
  • 2 passport sized photographs.
  • A copy of your current qualification
  • Your payment
For Office Use Only
Completed application form   Membership number  
2 Passport sized photographs   Card issued  
Copy of current qualification   Date of joining  
Payment   Database updated