ADC2 – Application for Diver Competence Certificate Replacement

Diver details
*Title	*Forename	*Family Name
*Date of Birth	*Nationality	*Phone No
*Email Address
Address Line 1	(eg building name)
Address Line 2	(eg street)
Address Line 3	(eg district)
*Town
County
*Postcode	Country

*Which certificate(s) have been lost/stolen? (Please select appropriate option(s) and provide certificate number if known)
Certificate No	Certificate No
SCUBA	Part IV
Surface Supplied	Part III
Surface Supplied (Top-up)	Part I
Closed Bell	Part II
Media / Archaeologist
AODC
MSC / TA

*An account of the circumstances in which the certificate was lost or stolen
Address at time the lost/stolen certificate was issued (if different to above) including postcode

Declaration

I confirm that my original HSE Diver Competence Certificate has been lost/stolen and that the information which I have supplied in connection with my application for a replacement certificate is true to the best of my knowledge and belief.

If the lost/stolen certificate is found subsequently, I promise to return it immediately to the Health and Safety Executive.

Name	Date
Signature

IMPORTANT NOTES:

It is a criminal offence, punishable with a fine and/or imprisonment, for a person to make any statement which that person knows to be false, or to recklessly make a false statement, for the purpose of obtaining a replacement certificate.

Send your completed, signed and dated form, a recent signed photograph of yourself and a copy of photographic proof of identity (photocopy of passport / driving licence / national ID card) to: Health and Safety Executive, Diving Operations Strategy Team, Roseberry Court, Central Avenue, St Andrews Business Park, Norwich, NR7 0HS.

FOR OFFICIAL HSE USE ONLY

Certificate Number	Date of Despatch