CFD Tank Fills Pay in Store

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Certification Number*

Certification Agency*

I understand that diving with compressed air involves certain inherent risks; including but not limited to decompression sickness, embolism or
other hyperbaric/air expansion injury that require treatment in a recompression chamber.

I understand and agree that neither Cruise Fish Dive or its staff, "the Released Parties", filling the cylinder(s) with compresses air or nitrox, may be held liable or responsible in any way for any injury, death or other damages to me, my family, estate, heirs or assigns that may occur as a result of my use of any cylinders filled by Cruise Fish Dive or its staff.

I further release, exempt and hold harmless Cruise Fish Dive and its staff of any claim or lawsuit by me, my family, estate, heirs or assigns, arising out of my injury of death from the result of using the cylinder filled by Cruise Fish Dive or its staff.

I further state that I am of lawful age and legally competent to sign this liability release, or that I have acquired the written consent of my parent or guardian. I understand the terms herein are contractual and not a mere recital, and that I have signed this Agreement of my own free act and with the knowledge that I hereby agree to waive my legal rights. I further agree that if any provision of this Agreement is found to be unenforceable or invalid, that provision shall be severed from this Agreement. The remainder of this Agreement will then be construed as though the unenforceable provision had never been contained herein.

I understand and agree that I am not only giving up my right to sue the Released Parties but also any rights my heirs, assigns, or beneficiaries may have to sue the Released Parties resulting from my death. I further represent I have the authority to do so and that my heirs, assigns, or beneficiaries will be estopped from claiming otherwise because of my representations to the Released Parties.

Date dropped off*

Tank Information (empty tank requires Visual Inspection)*

VIP Tank Fill Service

Select this option if you need before or after hour service or if dropping off within 30 minutes of closing. Max of 4 cylinders per. Select an additional VIP per every 4 tanks. You may also skip the line with this option and we will fill your tanks while you wait.

Signature of Payee. By signing I am stating I agree to all of the terms and conditions and authorize Cruise Fish Dive to charge my credit card. I understand there are no refunds for this service. Equipment left for more than 30 days will incur a minimum storage fee of $25 per month. If not claimed within 90 days, I authorize CFD to dispose of or sell my equipment.*