NAUI Technical Instructor Application Checklist

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1 NAUI Technical Instructor Application Checklist NAUI Technical Course Instructor Application Form NAUI Technical Diving Logbook Documentation NAUI Technical Instructor Agreement The items checked above have been verified by me and are included in this submission. Print Name: NAUI #: Signature: :

2 PERSONAL INFOMATION: Instructor Number: Last Name: First Name: M.I. Address: Address: City: State: Zip: Country: Tel (evening): Tel (daytime): Technical Instructor Course Names: Introduction to Technical Diving Cave Diver Level I Sidemount Diver Cave Diver Level II Technical Decompression Diver Cave Guide (Technical Support Leader) Technical Support Leader Wreck Penetration Diver Helitrox Diver Technical Wreck Penetration Diver TriMix Diver Ice Diver Extreme Exposure Diver Diver Propulsion Vehicle (DPV) Diver Semi-Closed Rebreather Diver Diver Propulsion Vehicle Extreme Exposure Closed Circuit Rebreather Diver Other: CCR Mixed Gas Diver System Requested: Extreme Exposure CCR Mixed Gas Diver System Requested: Mixed Gass Blender and O2 Service Tech System Requested: Cavern Diver System Requested: For TECHNICAL DIVING COURSES, I have attached the following required document(s) (For required documents, see NAUI Standards and Policies Manual, 2012 Edition.) TRAINING BACKGROUND: Evidence of relevant training and/or experience for the selected course(s) must be submitted with this application. Technical Certifications / Level: Example: Trimix Diver / Diver NAUI Technical Instructor Course Application Agency Certification Expiration I certify that information provided above is true and correct to the best of my knowledge. Applicant s Signature NAUI Technical Course Director Training Department This is an application to attend a NAUI Technical Instructor Course(s). Successful completion of the courses to be taught is required to obtain authorization.

3 Technical Diving Documentation Please document twenty (20) of your most recent technical dives. A technical dive is defined as one requiring staged decompression, multiple gas use, or using a rebreather. 1. Attest that you have completed fifty (50) or more dives in the specialty for which you are applying. 2. Sign this form have it notarized and return to the workshop director for the processing of your NAUI Technical Course Instructor Application. Dive # Dive Location Depth/Time/Gas of Dive The dives listed above document my most recent experience for application as a Technical Diving Instructor. I attest that I have completed fifty (50) or more dives in this technical diving discipline. Instructor Name Signature

4 Instructor Name (Print) Training Department 9030 Camden Field Parkway Riverview, FL 33578, United States of America (813) Voice (813) Fax Member Number # Technical Instructor Agreement Dear Member, This letter is an agreement. A signed copy by the NAUI Technical Course Director and you, received by the NAUI Training Department will confirm your designation as a NAUI Technical Instructor, and confer certain responsibilities and privileges to teach specific NAUI technical diver courses. After you have studied the agreement carefully and, if you agree to the terms described herein, sign and return the original to the Training Department, and keep one for your records. The term of this agreement is for two calendar years including the year in which it is signed. Privileges Designation as a NAUI Technical Instructor authorizes you to conduct the following technical diver courses until such time as the designation is suspended or revoked or you receive written notice of required update training: is required for each course qualification earned. Intro to Tech Diving Sidemount Diver Technical Decompression Diver Technical Support Leader (TSL) Helitrox Diver Trimix Diver Extreme Exposure Diver Semi-Closed Rebreather Closed Circuit Rebreather Closed Circuit Rebreather Mixed Gas

5 Extreme Exposure CCR Mixed Gas Mixed Gas Blender & O2 Service Tech Cavern Diver Cave Diver Level I Cave Diver Level II Cave Guide (TSL) Wreck Penetration Technical Wreck Penetration Ice Diver Diver Propulsion Vehicle (DPV) Diver Technical DPV Diver Responsibilities, Suspension and Revocation As a NAUI Technical Instructor, I understand and agree that technical courses I conduct must comply with NAUI diving course standards, policies, guidelines and Training Department directives. Failure to comply while teaching the above-named courses is cause for suspension or revocation of my Technical Instructor designation by the NAUI Training Department. Such designation can only be suspended or revoked in writing as per the Designated Instructor Review Procedure. The specific reason(s) for suspension or revocation of privileges (such as a required update or failure to comply with standards) will be disclosed in the letter and a copy of the Designated Instructor Review Procedure will be provided. Appeals regarding suspension or revocation of the technical instructor designation shall be made in writing to the NAUI Membership Review Committee at NAUI headquarters within ten (10) days of receipt of such notice. A review of the circumstances which led to the suspension or revocation will be conducted and a decision rendered within ten (10) days. No further appeal will be considered by other NAUI authority. Name: NAUI No. Technical Instructor (Please Print) Signature: : Name: NAUI No. Technical Course Director (Please Print) Signature: :

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