Date : ____________

Name : _______________________________________

Address: _______________________________________

City/State/Zip: _____________________________________

County: __________ Email Address: _________________

Home Phone: _________

Affliation __________________ Cell Phone:__________

Certification Agency: ____________ Year:__________

Amount Enclosed $ _____________
PLEASE CHECK DESIRED Membership

GLACD INDIVIDUAL MEMBER
( )$10 (E-mail Delivery of Notices)
( )ADD $15 Underwater Society of America Dues (Optional)

( ) GLACD ASSOCIATE MEMBER (BUSINESS) $35
( ) GLACD SUPPORTIONG CLUB $35

PRINT OUT AND MAIL TO: GLACD, P.O. BOX 6255, Torrance, CA 90504

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