Fillable CERTIFICATION CARD REPLACEMENT FORM

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CERTIFICATION CARD REPLACEMENT FORM

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The CERTIFICATION CARD REPLACEMENT FORM form is 2 pages long and contains:

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  • 8 check-boxes
  • 55 other fields

Country of origin: OTHERS
File type: PDF

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NATIONAL ASSOCIATION OF UNDERWATER INSTRUCTORS HEADQUARTERS
9030 Camden Field Parkway, Riverview, FL 33578 • Phone 813-628-6284 • Fax 813-628-8253 • www.naui.org • nauihq@naui.org
• Fill this form out completely, including all italicized information. Processing times may be delayed if: your certication was outside of the U.S., more than 20 years ago,
or if we need to verify your information with the instructor. For quicker processing time, include copies of any documentation you may have (i.e. wall certicate, photocopy of
original card, instructor-signed training log pages.)
• If asking for a name change, include a clear copy of your Photo ID (Passport or Driver’s License) and legal documents.
• Checks are not accepted. This form may be faxed to +1 813-628-8253.
• To Order a Replacement ONLINE, sign in or create a FREE ACCOUNT at core.naui.org.
• Photos uploaded to your CORE account prole will be printed on all certication cards.
CERTIFICATION CARD REPLACEMENT FORM
First/Given Name (or send copy of legal change)
Middle Initial Last/Family Name
Course Level
(Scuba, Advanced, Master, etc.) Course Date (MM/YYYY) Date of Birth (MM/DD/YYYY) Name at time of Certication (if different)
Address at time of Certication
City County State/Province Zip/Postal Code
NAUI Instructor Name NAUI Instructor #
I do hereby swear, under penalty of perjury, that I am at least 18 years of age, that I was issued a NAUI certication card as indicated above on or about the date indicated above. I
further state that I have lost the card which was issued and, after a thorough search, can nd no other information except that provided above to substantiate this afdavit. I hereby
release NAUI, its members, directors, and ofcers from any and all liability that may arise as a result of accepting, as true, this afdavit and issuing a replacement card.
Quantity Description Price Extended Amount
Standard Replacement Card(s) (Upload a photo at www.core.naui.org) $45.00
Digital Card(s) (Upload a photo at www.core.naui.org) $20.00
Replacement Certicate $26.00
Digital Bundle (Plastic + Digital Card) $50.00
For Member or Afliate participants, use member # or Afliate # for price level.
TOTAL $
Signature
NATIONAL ASSOCIATION OF UNDERWATER INSTRUCTORS
Order Form (All prices are subject to change without notice)
* Actual Shipping Rates will be Charged. Select Shipping Option:
____
Standards Shipping (3-7 days delivery time after processing.)
____ FedEx Next Day Delivery **
____ International Priority Service
* If no option is selected, we will use FedEx Ground. Actual rates will be charged. Rates are
subject to change as carrier rates change. Fuel surcharges are included where applicable.
** These services may not be available for APO addresses, PO Boxes or areas outside of the
United States. Weekends and holidays are not included in delivery time. Call member services
for details.
* In the event the requested records are not in the NAUI electronic database and must be researched in our hardcopy archives, I approve a $20 charge as a
research fee in order to complete my order. If the certication records are not located, the $20 research fee will still apply. However, if the records are located,
the $20 research fee will be applied to the replacement cost of the requested certication.
Required Initials
Instructions
Name
Phone Number Email
Shipping Address
City County State/Province Zip/Postal Code
Shipping Information
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signature
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CREDIT CARD #
o
American Express
o
Discover
o
Visa
o
MasterCard
o
Money Order#________________________
PAYMENT METHOD
(Must provide payment at time of application submission.)
CARD HOLDER’S SIGNATURE
MM / YY
Amount Enclosed $
CARD HOLDER’S NAME (PRINT)
CVV Code:
Expiration Date:
NATIONAL ASSOCIATION OF UNDERWATER INSTRUCTORS HEADQUARTERS
9030 Camden Field Parkway, Riverview, FL 33578 • Phone 813-628-6284 • Fax 813-628-8253 • www.naui.org • nauihq@naui.org
Certication Replacement Card Form Rev 4/1/19
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CERTIFICATION CARD REPLACEMENT FORM

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Completed 19 February 2022

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