INTERNATIONAL LIFE SAVING
FEDERATION
Gemeenteplein 26, 3010 Leuven, Belgium.
Tel [phone] Fax [phone]
E-mail: [e-mail] Web: http://www.ilsf.org
REQUEST FORM FOR INTERNATIONAL CERTIFICATE
FEDERATION: WODNE OCHOTNICZE POGOTOWIE RATUNKOWE
The above mentioned Federation herewith confirms that the following
Please add 2 individual has fulfilled all conditions set forward by ILS.
photographs to
each request
Name: __________________________________________________
·1 to be glued
Forename: _______________________________________________
here
Date of birth: . . / . . / . . . .
·1 for the identity
card
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