| Membership Application |
| To join us, please print and mail this completed form to: The Lost Patrol Dive Club P.O. Box 9652 Marina Del Rey, CA 90295 Membership: Club activities are now funded through a small surcharge on events rather than dues! Name: __________________________________ Date: _____________ Address: _________________________________ City: ___________________________ State: ___________ Zip:________ Home Phone: _________________ Work Phone:_________________ E-mail: ____________________ Certification Number: ________________ Level: ____________ Agency: PADI NAUI Other: _______ Certification Date: ______________________ |