Onshore Supervisor Diploma Assessment Application Form Have you read and understood the ADAS Conditions of Certification?* Yes View the ADAS Conditions of Certification.Application TypePlease select which type of onshore supervisor certification your Diploma relates to*Aquarium supervisor: $350 + GSTAquaculture supervisor: $350 + GSTPart 1 only supervisor (SCUBA to 30m): $350 + GSTPart 2 only supervisor (SSBA to 30m): $350 + GSTPart 3 only supervisor (SSBA to 50m): $350 + GSTPart 1 & 2 supervisor (SCUBA & SSBA to 30m): $350 + GSTPart 1 & 3 supervisor (SCUBA to 30m & SSBA to 50m): $350 + GSTApplicant DetailsADAS NumberName* First Last Postal Address* Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Shipping Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePlease select a shipping country to ensure your items are delivered correctly.Residential Address* Same as previous Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Mobile/Cell*Email* Is your billing address different?* Yes Billing addressIf your employer will be paying for your application, please enter the company details here.Company Details* Company Name Contact Name Email Address Company / Billing Address* Address Line 1 Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Competency & QualificationsAre you satisfied that you have completed all components of the Introduction to Dive Project Supervision course?* Yes Please attach your log book*Accepted file types: jpg, jpeg.Attach a copy of your logbook showing you have completed at least 80 hours in a supervisory role since you gained your ADAS Onshore Supervisor certification. Logs must be signed by a contractor and show the company stamp. Files accepted: jpg, png, pdf, doc, docx, jpeg.Please attach a high quality passport style photo*Accepted file types: jpg, jpeg.Photo to be taken within the last twelve (12) months. Files accepted: jpg, jpegPlease attach a high quality copy of your passport or alternative identification (e.g. drivers licence, ID Card)*Accepted file types: jpg, png, pdf, doc, docx, jpeg.Files accepted: jpg, png, pdf, doc, docx, jpegDeclarationApplicant Declaration* I agree to the following I understand and warrant that, by my submission of all information herein electronically, I acknowledge that all information is submitted on the basis that it is truthful in its entirety and has the same effect as if I had personally executed this application. I understand that my electronic submission of the information herein, entitles ADAS, its Officers, Servants and/or Agents, to rely upon same as being truthful and accurate and I indemnify, and keep indemnified, all Parties that rely upon the information electronically submitted therein in the event that any such information is found to be false and/or misleading.Additionally, I understand, and agree to abide by, the conditions set out in the "Conditions of ADAS Certification" and that in making this application I am certifying that I: am current in the practical and theoretical skills and knowledge relevant to my level of ADAS certification as identified in the ADAS Diving Competency Standards; hold current First Aid, Oxygen Management, and CPR qualifications in accordance with Australian national requirements; have current medical certificates that meet requirements for occupational diving (if relevant). I also understand that I may be required to demonstrate to ADAS though the provision of log books or other appropriate equivalent evidence how those relevant skills and knowledge have been maintained. Application PaymentNote: GST is applicable to Australian destinations only.Australian shipping and handling Price: $ 4.50 International shipping and handling Price: $ 15.50 GST included in total: Price: $ 0.00 Total Payment Due: $ 0.00 How would you like to pay?*Credit CardPaypalBill to CompanyBank Cheque or Money OrderNote: If you're paying by credit card or PayPal, you will be transferred to a secure payment page when you click submit. Once payment is complete you will be returned to our website. If your company is paying for your application/order please ensure you enter all the relevant details in the 'Billing Address' section.Please make cheque or money order for payable to: "ADAS" and mail to 526 Duncan Road, Dunoon, NSW, 2480. Please allow approximately 7-10 working days for payment to be received.