FULL NAME 

ADDRESS 

CITY,ST,ZIP 

TELEPHONE # 

FAX # 

E-MAIL ADDRESS

DATE OF BIRTH 

OCCUPATION 

YEARS BOATING EXPERIENCE    

YEARS AS A BOAT OWNER 

SIZE AND MAKE OF BOATS OWNED 

SIZE AND MAKE OF BOATS OPERATED 

HAVE YOU TAKEN ONE OF THE FOLLOWING COURSES:

COAST GUARD USCG     Yes    No

POWER SQUADRON        Yes    No

ANY CLAIMS IN LAST 3 YEARS? 

ANY VIOLATIONS ON DRIVING RECORD? 

BOAT/YACHT