Service Order Form Choose 1 Details 2 Payment 3 Insurance 4 Type of Insurance Please selectMembership including DIVING INSURANCE for a SINGLE diver - 229 NIS Membership including DIVING INSURANCE for FAMILIES - 184 NIS for each Membership including DIVING INSURANCE for GROUPS (10 or more DIVERS) - 189 NIS for each Membership including DIVING INSURANCE for COUPLES - 199 NIS for eachMembership fees include diving insurance for students - 189 NISMembership including DIVING INSURANCE and an active instructor fee - 329 NISMembership including DIVING INSURANCE for soldier - 159 NISMembership fees include insurance for scientific diving - 429 NIS Membership fee includes diving insurance for ZAKA volunteers - 429 NIS Passport or ID number no letters only numbers Id type Israeli id number Other Birth Date Birth Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Birth Month Month123456789101112 Birth Day Day12345678910111213141516171819202122232425262728293031 Hebrew first name Hebrew last name First name Last name Gender Female Male Street pob City/State/Province Zipcode Cellphone Extra Phone E-Mail Diver level Choose diver levelOpen water diverAdvanced Open water diverDivemasterAssistant InstructorOpen Water InstructorJunior adv open water diverDeep DiverClub Diver Rescue DiverTechnical DiverTRIMIX DIVER Closed / semi-closed systems diverADV. TRIMIX DIVER Club diverMaster DiverNitrox DiverAdvanced Open water + Nitrox Diver Certification agency Sub Insurant No. 1 Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Birth Month Month123456789101112 Birth Day Day12345678910111213141516171819202122232425262728293031 Hebrew first name Hebrew last name First name Last name Gender Female Male Street pob City/State/Province Zipcode Cellphone Extra Phone E-Mail Diver level Choose diver levelOpen water diverAdvanced Open water diverDivemasterAssistant InstructorOpen Water InstructorJunior adv open water diverDeep DiverClub Diver Rescue DiverTechnical DiverTRIMIX DIVER Closed / semi-closed systems diverADV. TRIMIX DIVER Club diverMaster DiverNitrox DiverAdvanced Open water + Nitrox Diver Certification agency Sub Insurant No. 2 Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Birth Month Month123456789101112 Birth Day Day12345678910111213141516171819202122232425262728293031 Hebrew first name Hebrew last name First name Last name Gender Female Male Street pob City/State/Province Zipcode Cellphone Extra Phone E-Mail Diver level Choose diver levelOpen water diverAdvanced Open water diverDivemasterAssistant InstructorOpen Water InstructorJunior adv open water diverDeep DiverClub Diver Rescue DiverTechnical DiverTRIMIX DIVER Closed / semi-closed systems diverADV. TRIMIX DIVER Club diverMaster DiverNitrox DiverAdvanced Open water + Nitrox Diver Certification agency Sub Insurant No. 3 Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Birth Month Month123456789101112 Birth Day Day12345678910111213141516171819202122232425262728293031 Hebrew first name Hebrew last name First name Last name Gender Female Male Street pob City/State/Province Zipcode Cellphone Extra Phone E-Mail Diver level Choose diver levelOpen water diverAdvanced Open water diverDivemasterAssistant InstructorOpen Water InstructorJunior adv open water diverDeep DiverClub Diver Rescue DiverTechnical DiverTRIMIX DIVER Closed / semi-closed systems diverADV. TRIMIX DIVER Club diverMaster DiverNitrox DiverAdvanced Open water + Nitrox Diver Certification agency Sub Insurant No. 4 Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Birth Month Month123456789101112 Birth Day Day12345678910111213141516171819202122232425262728293031 Hebrew first name Hebrew last name First name Last name Gender Female Male Street pob City/State/Province Zipcode Cellphone Extra Phone E-Mail Diver level Choose diver levelOpen water diverAdvanced Open water diverDivemasterAssistant InstructorOpen Water InstructorJunior adv open water diverDeep DiverClub Diver Rescue DiverTechnical DiverTRIMIX DIVER Closed / semi-closed systems diverADV. TRIMIX DIVER Club diverMaster DiverNitrox DiverAdvanced Open water + Nitrox Diver Certification agency Sub Insurant No. 5 Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year1949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 Birth Month Month123456789101112 Birth Day Day12345678910111213141516171819202122232425262728293031 Hebrew first name Hebrew last name First name Last name Gender Female Male Street pob City/State/Province Zipcode Cellphone Extra Phone E-Mail Diver level Choose diver levelOpen water diverAdvanced Open water diverDivemasterAssistant InstructorOpen Water InstructorJunior adv open water diverDeep DiverClub Diver Rescue DiverTechnical DiverTRIMIX DIVER Closed / semi-closed systems diverADV. TRIMIX DIVER Club diverMaster DiverNitrox DiverAdvanced Open water + Nitrox Diver Certification agency Total: NIS Send חידוש ביטוח / רכישת ביטוח
