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PRO APPLICATIONSSI DIVE PROFESSIONAL UPGRADECROSSOVER APPLICATION

991252 ATTENT ION Di ve Profile Must Be Created in ODiN Prior to Form Submission mdash

SSI PRO LEVEL APPLYING FOR nTRAINING SPECIALIST nSPECIALTY INSTRUCTORSee Standards for Prerequisites - Check Only One See Standards for Prerequisites - Check All That Apply Counts Toward Training Specialist

Dive Guide Use This Form In Addition To Training Record

When Applying For Additional Ratings

Digital PhotoVideo

Altitude Diving

Boat Diving

Classified Diving

Deep Diving

Diver Stress amp Rescue

Dry Suit Diving

Enriched Air Nitrox Diving

Equipment Techniques

Fish Identification

Ice Diving

Navigation Night amp Limited Visibility

Perfect Buoyancy

React Right CPRFirst AidAEDO2 Prov

Recreational CCR Diving

Recreational CCR Deep Diving

Recreational Sidemount Diving

Recreational Wreck Diving

River Diving

Science of Diving

ScooterDPV Diving

Scuba Rangers

Search amp Recovery

Shark Diving

Waves Tides amp Currents Other ___________________________

Other ___________________________

Divemaster Use This Form In Addition To Training Record

When Applying For Additional Ratings

Dive Control Specialist Use This Form In Addition To Training Record

When Applying For Additional Ratings

Open Water Instructor Use This Form In Addition To Training Record

When Applying For Additional Ratings

Advanced Open Water Instructor

Divemaster Instructor

Dive Control Specialist Instructor

Master Instructor

Instructor Trainer (no crossover)

Update

Candidate (Please Initial) Verifying InstructorInstructor Trainer (Please Initial)

Candidate Agrees

___ Create and Maintain an updated ODiN Profile including picture and

email address

___ Provide proof of a medical signed by a physician not older than 1 year

___ Provide proof of CPRFirst AidOxygen Provider not older than 2 years

Medical and proof of CPRFirst AidOxygen Provider must be uploaded in ODiN Profile

___ Adhere to all points listed in the Dive Professional Agreement

(see back of this form)

___ Crossovers ONLY ndash Provide proof of all current professional levels held bycurrent agency

Verifying InstructorInstructor Trainer Agrees

___ All prerequisite per Standards met for the applicable rating(s)

___ The candidate has successfully met or completed all requirements for

the applicable rating(s)

___ Candidate has understood and signed Dive Professional Agreement

(see back of this form)

PRIVACY STATEMENT amp CONSENT FORMI understand and agree that for the purpose of dive professional training and for verification of my certification SSI will retain the personal information I have provided to

them during my training which includes but is not limited to my name mailing address email address phone number date of birth photograph and dive professional

certification number

This personal information will be stored in SSIrsquos database also referred to as ODiN SSI will take reasonable steps to ensure that this data is protected and I will be given a

username and password which will allow me to access the SSI database and verify that my personal information contained therein is correct current and accurate

I consent to SSI an SSI authorized affiliate or an SSI subsidiary accessing this information for purposes of verifying my dive professional certification

Print Name of Instructor Candidate Crossover Dive Professional DATE Instructor Candidate Crossover Dive Professional Signature ODiN

Print Name of Verifying InstructorInstructor Trainer DATE Verifying InstructorInstructor Trainer Signature ODiN

First Name MI Last Name

n Male nFemale of Dives

Dive Center Affiliation

Dive Center Number nUpgrade nCrossover

Upgrade SSI ODiN Pro

Current Agency _______________________________________________________

XOVER Current Pro Member Since ________________

DATE OF BIRTH

JAN MAY SEPT

D A Y

Y E A RFEB JUNE OCT

MAR JULY NOV

APR AUG DEC

991252 PRIVACY STATEMENT amp CONSENT FORM mdash

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SSI DIVE PROFESSIONAL AGREEMENT

Print Name of Instructor Candidate Crossover Dive Professional DATE Instructor Candidate Crossover Dive Professional Signature

As an SSI Dive Professional I hereby agree to the standards and requirements set forth by SSI including but notlimited to this SSI Dive Professional Agreement

1 Abide by rules and regulations as now and hereafter established by SSI fulfill the SSI Training Standards as now andhereafter established by SSI and issue certifications only to people who meet the intent as well as the requirements set forth inthe SSI Training Standards

2 Act in a professional manner to reflect positively of yourself SSI Authorized Dive Centers SSI Authorized Dive Resorts andSSI

3 Teach programs approved by the SSI Dive Center Dive Resort you are affiliated with SSI Dive Professionals understands atraining director (or similar position) controls what programs are offered at the SSI Dive Center Dive Resort and the DiveProfessional may have training or may seek training in programs not approved by the SSI Dive Center Dive Resort

4 Obtain certification cards and education materials from the SSI Authorized Dive Center Dive Resort you are affiliated withand not from SSI SSI Dive Professionals understand that SSI certification cards and education materials are sold exclusively toSSI Authorized Dive Centers Dive Resorts

5 Abide by all Monitor Assessment Program (MAP) procedures as stipulated by the Monitor(s) at the SSI Dive Center DiveResort you are affiliated with SSI Dive Professionals understand the Monitor(s) for the SSI Dive Center Dive Resort you areaffiliated with are empowered to oversee and evaluate your compliance with the SSI Standards

6 Comply with all renewal procedures and agree to keep your personal contact information that is stored in the SSI databasecurrent at all times to ensure a communication flow

7 SSI Dive Professionals understand their SSI Dive Professional renewal is at the sole discretion of SSI Corporate Directors and a

mandatory update is required to become active again after a period of Inactive Status8 Carry professional liability insurance naming SSI as additional insured and provide proof of same (in countries where

applicable)

9 Indemnify save and hold SSI its officers and directors and assigns harmless for any loss claim or damage resulting from youracts as a Dive Professional or your agents students or assigns

10 Notify SSI prior to renewal and his her instructor prior to training and if convicted of a crime of moral turpitude (ie honestyintegrity morals sexual assault etcetera) Conviction of these crimes may result in ineligibility for renewal or SSI DiveProfessional certification

11 Notify SSI if you have been previously are currently or become the subject of any investigation action or proceeding due tostandards violation brought by any dive training agency SSI may at it sole discretion terminate his her certification

12 Authorize any other scuba diving association or organization with which you are affiliated to release any and all records andother information pertaining to any investigation action or proceeding involving SSI

13 Authorize SSI to release any and all records and other information pertaining to any investigation action or proceedingconcerning you to any other dive training agency

14 Pay all funds due to SSI within 30 days or at the date due whichever comes first I understand that failure to pay accounts due will result in loss of Active Status and collection proceeding

15 Obtain written authorization from SSI prior to any use of the SSI logos or trade names I understand that active status is inno way a license agreement between him her and SSI and that he she may not reproduce any existing SSI materials orproduce any new products using the SSI or any other corporate logos

16 I agree that I am not an agent employee or legal representative of SSI I have no authority to bind SSI in any manner Iam not involved in any co-venture joint venture or partnership with SSI and I am not automatically entitled to be an SSI

Authorized Dive Center Dive Resort

17 I understand it is my responsibility to know and abide by all current SSI Training Standards and all SSI Dive Professionalrequirements I understand these standards and requirements change periodically and I agree to be responsible for

maintaining and abiding by the most recent standards and requirements distributed by SSI18 I agree to inform my SSI Service Center about any changes to my physical condition which would be contradictory to

diving fitness and further agree to provide a new Medical Exam Form signed by a licensed medical practitioner to mySSI Service Center

19 I understand and agree that the SSI Dive Center Dive Resort creates an electronic set of personal information and forwards itto the SSI Service Center for the purpose of certification

20 I accept and agree that my SSI Service Center will be sending me the SSI Dive Professional additional information aboutstandards changes training bulletins updated training materials upgrade offers and diving in general

8182019 Universal Application english NEW 112015pdf

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SSI DIVE PROFESSIONAL AGREEMENT

Print Name of Instructor Candidate Crossover Dive Professional DATE Instructor Candidate Crossover Dive Professional Signature

As an SSI Dive Professional I hereby agree to the standards and requirements set forth by SSI including but notlimited to this SSI Dive Professional Agreement

1 Abide by rules and regulations as now and hereafter established by SSI fulfill the SSI Training Standards as now andhereafter established by SSI and issue certifications only to people who meet the intent as well as the requirements set forth inthe SSI Training Standards

2 Act in a professional manner to reflect positively of yourself SSI Authorized Dive Centers SSI Authorized Dive Resorts andSSI

3 Teach programs approved by the SSI Dive Center Dive Resort you are affiliated with SSI Dive Professionals understands atraining director (or similar position) controls what programs are offered at the SSI Dive Center Dive Resort and the DiveProfessional may have training or may seek training in programs not approved by the SSI Dive Center Dive Resort

4 Obtain certification cards and education materials from the SSI Authorized Dive Center Dive Resort you are affiliated withand not from SSI SSI Dive Professionals understand that SSI certification cards and education materials are sold exclusively toSSI Authorized Dive Centers Dive Resorts

5 Abide by all Monitor Assessment Program (MAP) procedures as stipulated by the Monitor(s) at the SSI Dive Center DiveResort you are affiliated with SSI Dive Professionals understand the Monitor(s) for the SSI Dive Center Dive Resort you areaffiliated with are empowered to oversee and evaluate your compliance with the SSI Standards

6 Comply with all renewal procedures and agree to keep your personal contact information that is stored in the SSI databasecurrent at all times to ensure a communication flow

7 SSI Dive Professionals understand their SSI Dive Professional renewal is at the sole discretion of SSI Corporate Directors and a

mandatory update is required to become active again after a period of Inactive Status8 Carry professional liability insurance naming SSI as additional insured and provide proof of same (in countries where

applicable)

9 Indemnify save and hold SSI its officers and directors and assigns harmless for any loss claim or damage resulting from youracts as a Dive Professional or your agents students or assigns

10 Notify SSI prior to renewal and his her instructor prior to training and if convicted of a crime of moral turpitude (ie honestyintegrity morals sexual assault etcetera) Conviction of these crimes may result in ineligibility for renewal or SSI DiveProfessional certification

11 Notify SSI if you have been previously are currently or become the subject of any investigation action or proceeding due tostandards violation brought by any dive training agency SSI may at it sole discretion terminate his her certification

12 Authorize any other scuba diving association or organization with which you are affiliated to release any and all records andother information pertaining to any investigation action or proceeding involving SSI

13 Authorize SSI to release any and all records and other information pertaining to any investigation action or proceedingconcerning you to any other dive training agency

14 Pay all funds due to SSI within 30 days or at the date due whichever comes first I understand that failure to pay accounts due will result in loss of Active Status and collection proceeding

15 Obtain written authorization from SSI prior to any use of the SSI logos or trade names I understand that active status is inno way a license agreement between him her and SSI and that he she may not reproduce any existing SSI materials orproduce any new products using the SSI or any other corporate logos

16 I agree that I am not an agent employee or legal representative of SSI I have no authority to bind SSI in any manner Iam not involved in any co-venture joint venture or partnership with SSI and I am not automatically entitled to be an SSI

Authorized Dive Center Dive Resort

17 I understand it is my responsibility to know and abide by all current SSI Training Standards and all SSI Dive Professionalrequirements I understand these standards and requirements change periodically and I agree to be responsible for

maintaining and abiding by the most recent standards and requirements distributed by SSI18 I agree to inform my SSI Service Center about any changes to my physical condition which would be contradictory to

diving fitness and further agree to provide a new Medical Exam Form signed by a licensed medical practitioner to mySSI Service Center

19 I understand and agree that the SSI Dive Center Dive Resort creates an electronic set of personal information and forwards itto the SSI Service Center for the purpose of certification

20 I accept and agree that my SSI Service Center will be sending me the SSI Dive Professional additional information aboutstandards changes training bulletins updated training materials upgrade offers and diving in general