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GREATER LOS ANGELES

COUNCIL OF DIVERS

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�Name :���� _______________________________________

Address:��� _______________________________________

City/State/Zip: _____________________________________

County:������ __________ Email Address: _________________��

Home Phone: _________

Affliation���� __________________�� Work Phone:__________

Certification Agency: ____________� Year:__________

Amount Enclosed $ _____________�
PLEASE CHECK�DESIRED Membership

GLACD INDIVIDUAL MEMBER
( )$15 (E-mail Delivery of Newsletter) or
(� )$20 Newsletter sent via US Mail
( )ADD $15 Underwater Society of America Dues (Optional)

( � ) GLACD ASSOCIATE MEMBER (BUSINESS) $35
( � ) GLACD SUPPORTIONG CLUB $35

PRINT OUT AND MAIL TO: GLACD, P.O. BOX 6255, Torrance, CA 90504




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