Komodo Hotel Registration | Blue Marlin Dive Komodo

Full Name *

Your Email *

Please enter a phone number below if you do not have a WhatsApp number

Phone/Mobile

Gender *

Nationality *

Zip/Pin/Postal Code *

Postal code of your home address

Date Of Birth *

Registration Location *

Do you have travel insurance?

Yes

No

Please ask our staff for available insurance plans for daily and weekly diving if you do not have an insurance that covers diving!

Does your insurance covers Diving *

Please ask our staff for available insurance plans for daily and weekly diving if you do not have an insurance that covers diving!

Insurance Provider *

Insurance Policy Number *

Passport Number *

Issuing Country *

Date of Expiry *

Upload Passport *

KTP Number *

Name on KTP *

Upload KTP *

Hotel Agent Name

Recreational Course *

Other Course *

Certified Diver *

No

Yes

Certification Level *

Certification No

Certifying Agency *

Upload Certificate

Emergency Contact Name *

Emergency Contact Phone

Emergency Contact Email

How did you hear about us? *

Please tell us how you heard about us *

Hotel Guest Registration