Freediver Instructor Freediver Instructor

Guide Code:
APPLICATION ______________________________

PLEASE PRINT CLEARLY Return certification package to:  Dive Center/Resort  Instructor Trainer  Applicant
 Please check here if this is a change of address and you want our records changed accordingly
DANIEL NARANJO RESTREPO 231746
Name _________________________________________________________________________________________ PADI No. ______________________
First Initial Last

AV SUR No 87-12 TORRE 2 APTO 104

Mailing Address _______________________________________________________________________________________________________________
PEREIRA ROSARALDA
City _________________________________________________________________________ State/Province ___________________________________
COLOMBIA
Country _____________________________________________________________________ Zip/Postal Code __________________________________
057-3122892000
Home Phone (______) ____________________________________________________ Business Phone (______) ________________________________
danielnr1967@hotmail.com
Email ________________________________________________________________________________ 25-03-1967
Date of Birth __________________________
Day/Month/Year

Gender Identity:  Man/Male ESPAÑOL

 Woman/Female  Non-binary/Non-conforming  Prefer not to say Preferred Language _____________________

To apply for and qualify as a PADI Freediver Instructor, meet prerequisite certification and training requirements as follows:

 PADI Master Freediver*

 or hold both of the following:

 PADI OWSI certification

 PADI Advanced Freediver*
 or hold both of the following:

 Qualifying freediver instructor certification*

 PADI Advanced Freediver*
 18 years old
 Current medical statement signed by a physician within the previous 12 months
 Emergency First Response (CPR/first aid) training withing 24 months*
 Completed one of the following:
 PADI Freediver Instructor Training course

 PADI Freediver Instructor Orientation (for qualifying freediver instructors from other organizations)

Bonai re
Course Location _______________________________________________________________________________________ 10 Apri l2024
Date ___________________
Day/Month/Year

Dive Center/Resort Name ________________________________________________________________________________ S – ___________________

Jesse duboi sJazzar

Trainer Name __________________________________________________________________________________________ 389619
No. ___________________

Instructor Trainer Signature ______________________________________________________________________________________________________

*Qualifying certifications from other organizations may be eligible.

Submit a copy of your qualifying course(s) with the application for review.

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PRODUCT NO. 10416 (Rev. 11/23) Version 1.03 © PADI 2023
Instructor Acknowledgment
“I agree to follow the PADI Freediver Program standards and understand that I may conduct the course(s) only after receiving written
approval from my PADI Regional Headquarters.
I have read the Membership Agreement and License Agreement (found in the Appendix of the PADI Freediver Program Instructor Guide)
and hereby consent and agree to the terms and conditions in their entirety. I understand and agree that any criminal conviction on my part
involving abuse of a minor or sexual abuse of an adult occurring either during or prior to my membership with PADI, will be automatic
grounds for denial or termination of my PADI Membership. I hereby certify that all the above statements are true and correct to the best of
my knowledge.”
10 Apri l2024
Instructor Signature ___________________________________________________________________________ Date ____________________________
Day/Month/Year

PAYMENT METHODS CARD OPTIONS

See current price list for application fee*.
 PADI Standard Card (no additional fee)
 American Express  MasterCard  VISA
08-27
Card expiration date _____________________
Support conservation – donate to receive the PADI AWARE
Foundation™ version of your certification card:
Card Number 4593560925791350
_________ _________ _________ _________  PADI AWARE Foundation Card __________
Cardholder Name daniel naranjo restrepo
_______________________________________ (Please indicate the amount of your donation.
Please Print Minimum of 10 AUD, CDN, CHF, EURO, GBP, or USD)
Authorized Signature _____________________________________ CHECKLIST
 Fees sent by bank transfer (Please include applicant’s full name,  Application completed in full
PADI Member number (if available) and note which credential appli-
cant is applyng for as a reference when making payments).  Copies of qualifying certifications/certification
counts attached
 Yes! Sign me up for Automatic Renewal
 Signatures
USING THE PAYMENT INFORMATION ABOVE

* Note that the application fee covers new member/membership-level  Payment information included
processing. Once certified, complimentary membership benefits are
extended to the end of this calendar year. To continue your member-  One photo attached
ship next year and onwards, you must renew annually.

OFFICE USE ONLY

Rec’d Code SUBMIT TO: Your PADI Regional Headquarters
Ent’d Paid For contact information, visit: www.padi.com
Shipped Initials
Reapplied Amount

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PRODUCT NO. 10416 (Rev. 11/23) Version 1.03 © PADI 2023