Participant Name:
Dr.
Ms.
Mr.
Mrs.
First Name
Initial
Last Name
Telephone Number:
Ext:
Email:
Fee Calculator
Current Date: September 7, 2010
# 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
2010
2011
2012
2013
2014
2015
2016
(Month / Year)
Card Holder Name:
If paying by money order, make payable to:
Xtreme Divers Inc.
Castillo del Mar 1316
4633 Isla Verde Ave.
Carolina, PR 00979
Last day to register online is February 5, 2010. Any day after that will have be to done at the DZ.
Comments or Questions:
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.