New York State Divers Association

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__________________________________________________________________
Would you like to receive the Dives Digest news letter on line? Y/N____

$5 discount for email digest only: Do not mail me a paper Digest____
NYSDA Individual, Group or Shop Registration - $25.00 ($20w/discount) $_________________
USOA Membership - $15 (NYSDA Member) $20 (Non NYSDA Member) $_________________
Additional Family members - $5 each List here ________________________________ $_________________
________________________________ $_________________
________________________________ $_________________

Total $_________________

Print this form
Fill it out and return to….. NYSDA
9226 Sly Hill Rd
Ava, NY 13303-1934

And Welcome to NYSDA

Click here for a interactive pdf form