Service Order Form Choose 1 Details 2 Payment 3 Insurance 4 Type of Insurance Please select Membership including DIVING INSURANCE for FAMILIES + - 334 NIS for each Membership including DIVING INSURANCE for COUPLES - 349 NIS for eachMembership including DIVING INSURANCE for a SINGLE diver - 379 NISMembership including DIVING INSURANCE for a compulsory soldier - 309 NIS Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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 Refresh Diving Yes No Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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 Refresh Diving Yes No Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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 Refresh Diving Yes No Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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 Refresh Diving Yes No Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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 Refresh Diving Yes No Passport or ID number Id type Israeli id number Other Birth Date Birth Year Year195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012 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 Different invoice details Invoice Details Name/Company Company Number Address Phone I have read the terms of the policy and agree to them, its terms and the terms of the transaction as detailed above I was not medically / mentally disqualified from diving activities. I am aware that if I was previously diagnosed positive for the Covid19 virus, I'm obligated to present medical authorization Confirming I am currently fit to dive. I agree to receive notices of renewal of insurance and benefits to members of the Association by email and / or contact information I have provided. Giving up receiving the plastic insurance card. It is important for me to reduce the sun in plastic (you can check online insurance validity) Number insurants: Total: NIS Send חידוש ביטוח / רכישת ביטוח
