White Star Quarry
                 901 South Main Street, Gibsonburg, Ohio 43431
                                   (419) 637 - DIVE (3483)

White Star Quarry Instructor Privilege application:

First Name:   Last Name:

Street Address:

City:

State/Province:

Country:

Your Postal Code:

Your Birth Date: MO Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec DAY 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 YYYY 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901

Your Instructor Number:

Which Agency? (Choose Primary):PADI NAUI SSI SDI/TDI ANDI IANTD YMCA Other

Your Email Address:

Your Dive Center/ Store affiliation:

All Fields Are Required to obtain your Instructor Pass. Each individual instructor must apply separately.

Your information will be kept completely confidential and will not be shared. Your instructor Pass and Pass Number will be available to you at the scuba concession at White Star Quarry.  If we have your insurance certificate on file we will mail you your pass.  You must present your Instructor credentials, certificate of insurance and sign a quality agreement at the scuba concession to obtain your Permanent pass on weekends after May 3, 2008. Please allow one week for your application to be processed.  If you require a pass prior to this date or need to make arrangements to pick up the pass at a different time, Please call (734) 971 7770.  You may fax your insurance sheet to (734) 971 2925 prior to May 3.

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