/ Application for Diving Certification

Part A

Family Name
First Name / Initial
Address
City / Province/State
Country / Postal Code/Zip

Address to which certificate should be sent, if different from above

Address
City / Province/State
Country / Postal Code/Zip
Date of Birth / dd/month/yyyy / Citizenship / Male/Female
Telephone / *Email
Category of certificate requested
Endorsement(s) requested

Declaration of Applicant

I, (print)______of the residence address noted above, do solemnly and sincerely declare that the statements made in this application are true and that the signed photographs included with this application are of me. Any false statement, misrepresentation or concealment of any material fact on this form or on any document presented in support of this application may lead to refusal or revocation of a certificate and be grounds for criminal prosecution.

Signature of Applicant / Date: dd/month/yyyy
DCBC may give my contact information and level of certificate to prospective employers / Initial here for YES / Initial here for NO
*I consent to receiving e-mail correspondence in relation to services and products offered by the DCBC / Initial here for YES / Initial here for NO

Part B(Only clear copies of original certificates, diplomas, and logbooks are acceptable)

Novice Applicant / Experienced Applicant
(Divers who recently completed initial commercial diver training) / (Includes experienced divers applying
for the first time)

1. Please confirm that the following mandatory documents are enclosed Y/N

Completed and signed application (Parts A and B)
Piece of photo identification to verify Date of Birth
Passport photo, or high resolution digital JPEG
Copy of current First Aid Certificate
Copy of current CPR/AED Certificate
Copy of current O2 Provider
Copies of diver/supervisor logs
Fee Payment (See website for payment options)

2. Indicate additional documents enclosed, if applicable Y/N

Diver Training Diploma
Supervisor Training Diploma
Shams/mock incidents
Copies of documentation to support endorsements (DMT, LST, etc.)
DP Induction or DP Introduction plus 700 panel hours on a DP vessel
DSS Applicants only – proof of successful completion of Regulatory Module Exam

3. List all domestic and foreign diving and dive related certificates held

Type / Date of Issue / Issued by / Number

4. Current and Previous Employers (List in chronological order, most recent first)

Company / From - To / Position / Country / Vessel/Rig/Installation

Return completed applications to DCBC by:

E-mail (do not exceed 10MB per e-mail) / Mail/Courier
/ 208-5209 St. Margaret’s Bay Rd
Upper Tantallon NS B3Z 1E3
F-7.2-01 Rev:01/03 / 27 May 2014 / Page 1 of 2