New York State Divers Association Membership Form
Title (Mr. Miss, Mrs. Ms. Dr.) :___________________ New Member (_) Renewal (_)
Name:_________________________________________________________
Occupation:_____________________
Address:_______________________________________________________________
City:_________________________________________ State:____________________
Zip:__________________
County:_______________________________ Phone (______) - _______ - ________
Certifying Agency:____________________________ Year:________
E-Mail:_____________________________
NYSDA Group or Shop Affiliation__________________________________________________________________
NYSDA Individual, Group or Shop Registration - $25.00 $_________________
USOA Membership - $15 (NYSDA Member) $20 (Non NYSDA Member) $_________________
Additional Family members - $5 each (Please List Below)
________________________________ $_________________
________________________________ $_________________
________________________________ $_________________
Print this form
Fill it out and return to….. NYSDA
9226 Sly Hill Rd Subtotal $_________________
Ava, NY 13303-9764
Total $_________________
And Welcome to NYSDA
For Microsoft Word File version of this application click here