Participant Name:
Dr.
Ms.
Mr.
Mrs.
First Name
Initial
Last Name
Telephone Number:
Ext:
Email:
Fee Calculator
Current Date: February 5, 2012
# of Jumpers:
x
$
# of Non-Jumpers:
x
$
Payment Information (U.S. Funds only)
Payment Method:
Visa
Master Card
Money Order
Total Amount Paid:
Card Number:
Expiration Date:
01
02
03
04
05
06
07
08
09
10
11
12
2009
2012
2013
2014
2015
2016
2017
2018
(Month / Year)
Card Holder Name:
If paying by money order, make payable to:
Xtreme Divers Inc.
4633 Isla Verde Ave.
Castillo del Mar #1316
Carolina, P.R. 00979
Last day to register online is February 8, 2012. Any day after that will have be to done at the DZ.
Comments or Questions:
By sending the registration you are agreeing to our
.