Training Reservation Form :: L.A. SCUBA DIVING :: Professional SCUBA Instruction Los Angeles

	Note: All Fields Required Customer Information
First Name
Last Name
Email Address
Phone
Home Address
City
State
Zip

	Select Your Course From The Menu:
	QTY Amount

	Select Course Dates:

	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"

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.