Dallas, TX 75230

Name:______________________________________ Date:___________________

Address:_______________________________________ Apt #: _______________

City:_____________________________ State:__________ Zip:______________

Home Phone: (____ )_________________ Work Phone: ( ____)______________

Fax: ( ____ ) ______________Email: ________________________________

Permission to release name and address to Photo/SCUBA related mailing lists:

No_____ Yes _____ signed: ___________________

Occupation: ___________________________

Diver Certification Organization: ________ ____ Level: _________

Dive Trips Per Year: _____ Years Diving experience:___________

Annual Dues (check one): Individual ($25) Family ($30) (Note: After July 1st $12.50 / $15)

If Family Membership, Please List Names and Pertinent Information:

Name Relationship Diver Certification Organization if certified

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How Did You Hear About This Club? _____________________

_________

Any Comments or Suggestions: ___________________________

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Photographic Information

Experience: (Mark ‘T’ for Top Side, ‘U’ for Underwater)

Beginning:_______ Intermediate:_____ Advanced: ___ Pro:

Interests: Still: Video:

Equipment: Nikonos: Housed SLR: Video Cam:

Movie Camera: Other:

Dallas Underwater Photographic Society

Membership Profile

Name: ______________________________

To what extent are you willing to get involved in the club

_________________________________________________________

What strengths, abilities, and possible networking would you be willing to contribute to the club?

___________________________________________________________

_________

What do you expect to get from being a member of this type of club? ____

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