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* Mandatory Fields

Applicant's Personal Information
Registered Owners First name*
Registered Owners Last Name*
Street Address*
Town*
Postal Code*
Date of Birth* (mm-dd-yyyy)
Home Number	( ) -
Business Number	( ) -
Cell Number	( ) -
Email Address*

Watercraft Information
Type*
Year (yyyy) *
Make*
Model*
Length (in feet)*	ft.
Boat Value (Boat & Motor) Including Taxes	$
Hull Construction
Watercraft Top Speed (miles per hour)	(mph)

Engine
Number of Engines
Type of Engine
Year (yyyy)
Make
Model
Horsepower	(hp)
If Out-Board Engine (Value of Engine)	$

Additional Watercraft Equipment
Electric Trolling Motor (Value)	$
Auxiliary Engine (Value)	$
Trailer (Value)	$
Dinghy (Value)	$
Dinghy Engine (Value)	$
Fishing Equipment (Value)	$
Portable Equipment (Value)	$

Watercraft Operators
Operator #1
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #2
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #3
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #4
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Operator #5
	Fist name
	Last name
	Date of Birth (mm-dd-yyyy)
Accredited Marine Training Course
	Yes No
	Description

Additional Information
Marine Survey Available	Yes No
Major Modifications On Watercraft	Yes No
Watercraft used for commercial Activities	Yes No
Watercraft used for racing	Yes No
Watercraft used in sailing competitions	Yes No
Watercraft used in poker runs	Yes No
Watercraft used for water skiing, Inflatable	Yes No
Watercraft used for wakeboarding	Yes No
Additional Comments
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