step1

Note: All Fields Required
 
Customer Information

First Name

Last Name
Email Address
Phone
Home Address
City
State
Zip
  

step2

Select Your Course From The Menu:
QTY    Deposit Amount 

step3

Payment Information

Credit Card

  

Is this a Business Card, Corporate Card or International Credit Card?
yes no

Card Holder Name
Card Number
Exp. Date

Signature

Check this box to electronically "sign" Course Policy
  


Please only push the submit button once. You will receive a confirmation on your screen in a few moments. Thank You.

  
Please Note:
By electronically "signing" and submitting this form you agree and authorize L.A. SCUBA DIVING to charge your credit card in the above amount, plus course materials & shipping/handling costs if applicable. Please make a note of this charge. Corporate Cards, Business Cards or International credit cards will be assessed a 3% service fee. Chargebacks will be assessed a chargeback fee of $75.00.