Q1 Date of dive(1st day) :

If you will participate for several days, You should only put the 1st date.

Q2 Your name :

Q3 Your nationality :

Q4 Your birthday :

Q5 Your Age :

Q6 Your gender :

Q7 Are you a resident of Palau? :

Q8 Your Address :

*If you are not Palau resident,please provide your address.

Q9 Your phone number :

Q10 Your e-mail :

Q11 Name of emergency contact person :

Q12 Relationship to emergency contact person :

Q13 Phone number of contact person :

Q14 Your dive experience :

Q15 When was the last time you dived? :

Q16 Your diving association :

Q17 Your diving certification level :

Q18 How many times have you visited Palau ? :

Q19 Which rental equipment would you like? :

Q20 Are you a certified diver for Nitrox? :

Q21 Which type of diving permit would you like us to prepare? :

Q22 Please fill in your desired diving sites and/or any other requests you have. :