MEMBERSHIP APPLICATION

Company Name:  ________________________________________________________

[  ]  Proprietorship     [  ]  Partnership     [  ]  Corporation    [  ]  LLC

Years in Business:  ____________________

Contact Person:  _______________________________________

Date of Birth: ___________________

Contact Person’s Position:  ________________________________

Years with Company: ____________

Business Address:  ________________________________________________________

City / State / Zip:  ______________________________________________________

Business Phone:  _______________________________

Fax:   __________________________________

Toll Free Phone:  ______________________________

Toll Free Fax:  _________________________

Home Phone: __________________________________

Cell:  __________________________________

Facebook: _____________________________________

WhatsApp: ________________________________

E-mail Address for directories:  ________________________________________________________

E-mail address for DIA correspondence: ____________________________________________________

Web Site (URL): ________________________________________________________

Trade Directory by-line (1-2 lines only): ____________________________________________________________

DEMA Member?  [  ] No   [  ] Yes
Number: __________   Votes: _____  Voting Delegate: __________________

Category – Business – (Choose One)  $125 Annual Membership Dues

[   ]  Manufacturer     [   ]  Distributor     [   ]  Retail Center     [   ]  Charter Boat
[   ]  Dive Club    [   ]  Service Provider     [   ]  Industry Media     [   ]  Trade Association
[   ]  Training Association    [   ]  Service Organization     [   ]  Trade Show Organizer
[   ]  Training Facility     [   ]  Travel Business

Category – Individual – (Choose One)  $75 Annual Membership Dues

[   ]  Sales Representative       [   ]  Professional Educator       [   ]  Industry Professional

Payment Method:  [   ]  Cash   /   [   ]  Check   /   [   ]  Credit Card   /   [   ]  PayPal   /   [   ]  Square

[   ]  Check (payable to Dive Industry Association, Inc.)   $ ___________
Check # _____________

[   ]  If paying by Credit Card, please fill out:  Type:
[   ] American Express   [   ] MasterCard   [   ] Visa

Card Holder’s Name: ________________________________

Credit Card #: _____________________________________

Expiration Date: ___________________________________

CVV: ___________________________________________

Zip Code: ________________________________________

Signature: ________________________________________

[   ]  Referred by:  ___________________________________

* DIA retains the right to re-classify members according to our membership standards.

Mail to: Dive Industry Association, Inc., 2294 Botanica Circle, West Melbourne, FL 32904-7339