Name:

Date of Birth:

Address:

City, State, Zip:

Home Phone:

Work Phone:

Email: *

Experience

Years as Owner:

Operator Since:

Will minors operate boat?

Yes   No

Qualifications

US Power Squadron
Coast Guard Aux
Coast Guard Nav
Capt/Masters License

Describe previous vessel
owned and operated
and vessel length:

Name

Birth Date

Driver's License #

State

Yrs Op

Yrs Own

Has any operator
sustained any boat/auto
violations in the
past 3 years?

Yes (details below)   No

Date

Violation

Operator

Cause/Result

Has any operator
sustained any boat/auto
losses in the
past 3 years?

Yes (details below)   No

Date

Circumstances

Amount of Loss

Has any operator
received a citation
for operating a watercraft
or motor vehicle while
under the influence of
alcohol or controlled
substances in the past
3 years?

Yes    No