CROSSOVER FORM If you have completed an ITDA Group International / IHMP Medical or Other ITDA Asia S.E. / International Technical Diving Agency, Crossover Program within the last 7-10 days, please register your details here. IF YOU ARE COMPLETING AN "ADMIN" CROSSOVER PLEASE COMPLETE PARTS and II of this form... Crossover Personal Details These details are required for both levels of crossover. Family Name* First Names* Date of Birth* Please attach an ID Photo 300dpi Jpeg format Current Certification Level* Any limitations to current certification? Please state here. Please check Agencies you are certified with? ITDA Group PADI NAUI SSI BSAC/SSAC CMAS National Federations IANTD TDI/SDI Other Crossover ITDA/Ref No. If applicable? Candidate Address / Contact Details Your Email Address* Alternative Email address? Postal Address* Post Code and Country* Home Telephone or Mobile* Emergency Contact Details Preferred Language for Contact? Part I. Crossover Program - Course Director / Trainer A minimum of one Course Director or one trainer is required to conduct an ICP (Instructor Crossover Program)... And an Assessor Examiner MUST or regional office staff must countersign / verify the Crossover Instructor's ability to be certified as an ITDA Group Professional. Any approved ITDA Group Centre may conduct the ICP Qualification process, including the Pre-ITP Exam. Your Name as Certifying Course Director* Director ITDA Group No/Ref* Director Email address* Certifying ITDA Trainer Name* Trainer ITDA IT No./Ref* Trainer Email address Dive Centre / Facility Dive Centre ITDA Group rating. ITDA Group Approved Centre ITDA Group Training Facility ITDA Group Premier Training Facility Not an ITDA Group Facility Assistants for Credit / Trainer Designate(s) or Crossovers Assistants may obtain full credit for training at an ICP and Pre-ITP providing each assistant completes at least one theory session and one practical session under the surpervision of a trainer or CD... For ICP Program credit, assistants MUST attend a minimum of one day. Assistant 1. Name Assistant 1. ITDA No./Ref. Assistant 2. Name* Assistant 2. ITDA No./Ref. Assistant 3. Name Assistant 3. ITDA No. / Ref Pre-ICP / ITP Administration Please include in this section all details about the IP or Pre-ITP Admin. Pre ITP Program Date* Pre ITP Certification Date.* Location / Address* Pre ITP Exam Score 95-100% 90-94% 80-89% Below 79% Candidate Registered for ITP where and when?* Candidate Completed ICP Date... Candidate Practical Skills Scores passed or failed, pass tick/check box, for fail leave blank. Basic Skills Equipment Environmental Advanced Buoyancy Navigation Leadership Skills Instructional Skills Teaching Skills Risk Assessment Assesment and Evaluation Skills Crossover Professional Certification Please include here each Instructor Level cro is or will be authorised to train and certify... ITDA Group Highest Instructor Level ITDA Group Instructor Levels to Certify CPR First Aid Instructor IMHP BLS Instructor IHMP Dive Medic Instructor Club / Resort Instructor Sports Instructor 2**Star Sports Instructor Ntech Nitrox Instructor Gas Blender Instructor Technical Instructor Specialist Instructor Level 1./Intro Certifed to Train Buoyancy Workshop Navigation Wreck Diving Deep Diving (30m/130 Equipment Marine Conservation Additional Specialist Levels pre qualified by experience to train and certify. Advanced Ntech/Nitrox Advanced Wreck Diving Night Diving Shark Diving Entry Level Trimix Trmix Diving DPV - Motorised Units SCR Rebreather CCR Rebreather Other Speciality Not listed.. Copy of Specialist Cards or Certificates as supporting evidence. Assessor Examiner Name Assessor Ref and ITDA No. Assessor Email contact CROSSOVER PART II. For those Crossovers who are self certifying, based on current professional level and in status with a recognised diving agency or federation / national body. Current Agency or Agencie(s) in Teaching Status with? Highest Current Certification Level Number of years teachnig Why are you Crossing over? ITDA Group HQ or Regional Office Admin ONLY ITDA Group International HQ or Regional Office Approval Code