Please forward the following items with your completed
application form to NBDHMT headquarters.
• 'Fitness to Work in Pressurized Settings' medical
clearance.
• Copy of your DOT/NHTSA approved emergency
medicine certificate or National Registry EMT, or
higher, certificate.
• Diving medicine course completion certificate.
• Diving medicine course instructor evaluation.
Last Name: First Name:
Home Address:
State/Province:
Postal Code:
Country:
Fees
DMT
®
Certification Fee ($125.00 USD):
Payment
Check or Money Order payable to NBDHMT
Credit Card
Card Number: Expiration Date:
Cardholder Name:
Mastercard
City:
Work Phone:
Work Fax:
Mobile Phone:Home Phone:
Email:
Name as it appears on your government issued I.D.
Zip Code:
Facility (Organization)
City: State:
Visa
CVC:
Diver Medic Certification
®
Form
For Office Use Only:
Date Received:
Payment Enclosed Payment Cleared
Recertification is required every two years. If DMT certification lapses, certification may be obtained within
one year from date of expiration. An additional fee of $50.00USD is charged. Maintenance of EMT, or higher,
status is required for recertification
If DMT certification has expired for more than one year, applicant must begin a new application and retake
certification exam.
Date of Birth:
National Board of Diving & Hyperbaric Medical Technology
9 Richland Medical Park, Suite 440, Columbia, SC 29203USA
Phone: (803) 434-7802 Fax: (866) 451-7231
Email: nbdhmt@aol.com
www.nbdhmt.org
