PERSONAL DATA
Number of Person
*
2
3
4
5
6
COMPLETE DETAILS
*
Rows
Person I
Person II
Person III
Person IV
Person V
Person VI
Full Name
Nick Name
Gender
Date of Birth
ID/Passport/KITAS No.
Email
Phone No.
Address
Nationality
DIVERS PROFILE
COMPLETE DETAILS
*
Rows
Person I
Person II
Person III
Person IV
Person V
Person VI
Diving Agency
Certification Level
Last Dive (Date & Place)
Current Dive Log
DAN Insurance (if any)
EMERGENCY CONTACT
COMPLETE DETAILS
*
Rows
Person I
Person II
Person III
Person IV
Person V
Person VI
Full Name
Date of Birth
Phone No.
Relation
SCUBA DIVING COURSE
Optional
Rows
Person I
Person II
Person III
Person IV
Person V
Person VI
Discount Course - Advanced Scuba (AOW): Rp. 850.000 (USD 65)
Discount Course - Emergency First Response (EFR): Rp. 750.000 (USD 57)
Free Course - Discover Scuba Diver (DSD)
Free Course - Deep Dive (Intro)
Please upload copy of each participant's ID Card (KTP/Passport/KITAS) - max. 1MB
*
Upload a File
JPG or PDF
Cancel
of
Please upload copy of each participant's Scuba Diving Certification Card - max. 1MB
*
Upload a File
JPG or PDF
Cancel
of
PAYMENT
Please make payment before submit
Select Your Payment
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PAYPAL (DEBIT OR CREDIT CARD PAYMENT)
BANK TRANSFER
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( X )
Diver Gathering 2018
$
310.00
Quantity
Advanced Scuba Diver - AOW (Optional)
$
65.00
Quantity
Emergency First Response - EFR (Optional)
$
57.00
Quantity
Subtotal
$
0.00
Tax
$
0.00
Total
$
0.00
Submit »
BANK TRANSFER
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KLIK BCA
MANDIRI ONLINE
*USE RIGHT CLICK ON YOUR MOUSE*
PAYMENT CONFIRMATION (please confirm your payment before submit)
Sender Name
*
Sender Bank or Paypal Account Name
*
Sender Account Number or Paypal Account Email
*
Total Amount
*
Transfer Date
*
Transfer Time
*
Payment For
*
Diver Gathering Event = IDR. 4.000.000 ($310)
Diver Gathering Event + AOW = IDR. 4.850.000 ($375)
Diver Gathering Event + EFR = IDR. 4.750.000 ($367)
Note
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