REPLACEMENT CARD ON-LINE

Dear SSI Diver,

We will be happy to help you replace your card. It is a very easy process. Simply send us the required information online. Be sure to include a photo. We will process and mail your new card within 24 hours of receiving this form and then your Diver Certification information will be available to view online at www.divessi.com . You will be able to login and print a copy of your card from anywhere in the world.

DIVER   INFORMATION (bold & asterisked items are required information)
(*) FIRST NAME    Middle Initial
(*) LAST NAME   
Photo File JPG no longer than 50K. 
(*) Date of Birth

      Sex

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
C-CARD  I N F O R M A T I O N
(*) YEAR CERTIFIED   Month Rating
(*) Number of Dives  

Specialties::

 Specialty Diver (2)

  Advanced (4)

Master (4) + S&R

                                       
SSI Card Number Card Number of Friend from Class
(*)AUTHORIZED DEALER     Instructor
(*) CITY      State/Country
PAYMENT  I N F O R M A T I O N
Please send me one (1) SSI replacement card for US$40.00
Also send me  Duplicate replacement cards (same name & rating for US$15 each)
Mailing 

Number Expires:   

Security Code (*)                                                                      (*)Security Code is the last 3 digit number printed on the back of your Master or Visa or the 4 digit number below the last number on the front of your American Express.

  I hereby swear that I have successfully completed an SSI course and was certified by SSI. I also affirm that the above information is correct. I authorize SSI to bill my credit card for the amount(s) indicated above.

SSL