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Membership Application

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Frank Panhuise
3924 Crooked Island Drive
Punta Gorda, FL 33950
First Name:
Last Name:
Nickname:
PGI Address: Street
City
State
Zip
In PGI: Year Round
Seasonal
Telephone (Home):
(Work):
(Cell):

Email Address:
Diving Certification Agency: Not Certified (yet)
NAUI
PADI
YMCA (SEI)
SSI
Other
Certification Level: Basic
Advanced
Master
Divemaster
Assistant Instructor
Instructor
Instructor Trainer
Other
List Other Certifications:
(Nitrox, Cave, etc.)
Diving Interests (check all that apply): Beach Dives
Boat Dives
Drift Dives
Wreck Dives
Fossil Hunting
Photo/Video
Hunting (Lobstering/Spearfishing)
Travel (local)
Travel (exotic)
Travel (liveaboards)
Other
Birthday: Month:     Birthday: