Personal Information

E-Mail:

Last Name: First Name: Spouse/Partner:

Home Address: City: State: New York New Jersey Conn. Florida Penn Other Zip:

Home Phone: Cell Phone: Work Phone:

Firm Name or Employer: Occupation:

Business Address: B. City: B. State New York New Jersey Conn. Florida Penn. Other B. Zip:

Emergency Contact: Relationship: Contact Phone:

Boat Information

Insurance Carrier: (a copy of your certificate must be on file at office before occupancy)

Boat Type: power sail Boat Construction Fiberglass Steel Wood other Boat Make: Boat Model:

Boat Year: Boat Color:

Boat LOA: (Length Over All Must include swim platforms, bow pulpits, etc.)

Boat Draft:: (Depth boat extends below the water.)

Boat Beam: (Width of the boat at it's widest point.)

Electrical Requirements: none single 30amp 125 volt twin 30amp 125 volt single 50amp 250 volt twin 50amp 250 volt (The minimum requirements your boat needs during summer months. )

Trailer Information

Trailer Color: Trailer Type: Bunk Roller Poppet other Trailer Year:

Seasonal Dockage and Storage Preferences

Winter Storage Preferences: Dry Wet

Questionaire

Is this a new boat? no yes

What was your previous marina?