do pobrania tutaj - WOPR-u

INTERNATIONAL LIFE SAVING
FEDERATION
Gemeenteplein 26, 3010 Leuven, Belgium.
Tel +32/16-35.35.00 Fax +32/16-35.01.02
E-mail: [email protected] Web: http://www.ilsf.org
REQUEST FORM FOR INTERNATIONAL CERTIFICATE
FEDERATION:
Please add 2
photographs to
each request
·1 to be glued
here
·1 for the identity
card
WODNE OCHOTNICZE POGOTOWIE RATUNKOWE
The above mentioned Federation herewith confirms that the following
individual has fulfilled all conditions set forward by ILS.
Name: __________________________________________________
Forename: _______________________________________________
Date of birth: . . / . . / . . . .
Place of birth: ____________________________________________
Language knowledge: ______________________________________
Address (street & n°): _______________________________________________________________
Zip + city: _________________________________________________________________________
Country: __________________________________________________________________________
Phone number: _____________________________________________________________________
e-mail: ____________________________________________________________________________
We request the following certificate(s):
International Junior Lifesaver
International Lifesaver (former FIS Lifesaver)
International Pool Lifeguard
International Inland Open Water Lifeguard
International Surf Lifeguard
International Lifesaver/Lifeguard Instructor (former FIS Moniteur)
International Open Water Diver (*)
International Rescue Diver (**)
International Rescue Dive Master (***)
International Rescue Dive Instructor (*)
International Rescue Dive Instructor (**)
International Rescue Dive Instructor (***)
International Rescue Boat Driver
Signature, Name and Function in the Federation
Date
Seal of Federation