PBCRRT Membership Form

Want to join? Renew? Change your personal data? Use this form. If joining, fill out the entire form.
If updating, fill out only your name and the section(s)you need to update. It self emails to Pug when you submit to the server.

Name
First	M.I.	Last
Address
Line 1		Line 2
City		State
Zip		Email
Phones
Night		Day
Dive Certs
OW	AOW    Agency:	Card Number
	Enter the higher card of OW or AOW.
Emergency	Contact
Insurer		Policy #
Name		Phone
Notes
	New Membership?         Renewing?         Updating Data?
	PBCRRT uses Florida Oceanographic Society as its not-for-profit organizational agent. Our dues are: Single membership: $30 for FOS + $10 for PBCRRT. Family membership: $50 for FOS + $10 per person for PBCRRT. Make check payable to: Florida Oceanographic Society Mark check memo for: Dues, FOS and PBCRRT. Give your check to the membership director at any meeting, or mail to: Lawrence Pugliese, 2741 Village Blvd # 403, West Palm Beach, Fl. 33409 You are not a member until your check arrives!