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Get Acuc Replacement Card

ACUC International 1264 Osprey Drive Ancaster Ontario Canada L9G 3L2 Tele 905 648-5500 Fax 905 648-5440 EMail acuc acuc.ca APPLICATION FORM FOR REPLACEMENT OF LOST CERTIFICATION CARD Name Address Male Female City/Province Postal Code Photo ID available upon request- please provide passport type picture head shoulders and print your name on the back of the photo and enclose with this form if you wish Photo ID. Please complete all areas of application form* Failure to complete all areas will cause delay in the processing of your new card. Has your name changed since you were certified No Yes Type of ACUC Course Open Water Diver Specialty Diver. Advanced Diver State Course Location Name of Store/Club/Aquatic Centre City Province Course Date MonthYear ACUC Instructor First Name Last Price 25. 00 US and International 25. 00 Canadian GST/HST Method of Payment Cheque Visa Master Card CODadd 5. 00 Canada only Credit Card Exp* Date Signature Date Please make cheque/money order payable to ACUC International Office use only File verification Mailed. Please complete all areas of application form* Failure to complete all areas will cause delay in the processing of your new card. Has your name changed since you were certified No Yes Type of ACUC Course Open Water Diver Specialty Diver. Has your name changed since you were certified No Yes Type of ACUC Course Open Water Diver Specialty Diver. Advanced Diver State Course Location Name of Store/Club/Aquatic Centre City Province Course Date MonthYear ACUC Instructor First Name Last Price 25. Advanced Diver State Course Location Name of Store/Club/Aquatic Centre City Province Course Date MonthYear ACUC Instructor First Name Last Price 25. 00 US and International 25. 00 Canadian GST/HST Method of Payment Cheque Visa Master Card CODadd 5. 00 US and International 25. 00 Canadian GST/HST Method of Payment Cheque Visa Master Card CODadd 5. 00 Canada only Credit Card Exp* Date Signature Date Please make cheque/money order payable to ACUC International Office use only File verification Mailed. Please complete all areas of application form* Failure to complete all areas will cause delay in the processing of your new card. Has your name changed since you were certified No Yes Type of ACUC Course Open Water Diver Specialty Diver. Advanced Diver State Course Location Name of Store/Club/Aquatic Centre City Province Course Date MonthYear ACUC Instructor First Name Last Price 25. Has your name changed since you were certified No Yes Type of ACUC Course Open Water Diver Specialty Diver. Advanced Diver State Course Location Name of Store/Club/Aquatic Centre City Province Course Date MonthYear ACUC Instructor First Name Last Price 25. 00 US and International 25. 00 Canadian GST/HST Method of Payment Cheque Visa Master Card CODadd 5. Advanced Diver State Course Location Name of Store/Club/Aquatic Centre City Province Course Date MonthYear ACUC Instructor First Name Last Price 25. 00 US and International 25. 00 Canadian GST/HST Method of Payment Cheque Visa Master Card CODadd 5. 00 Canada only Credit Card Exp* Date Signature Date Please make cheque/money order payable to ACUC International Office use only File verification Mailed.

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