Name:
__________________________________________________________________
Address:
________________________________________________________________
City: ______________________________
State: ___________ Zip Code: ___________
Home Phone: ____________________
Emergency or work phone:__________________
Pager (optional): ____________________
Email: _______________________________
Spouse or Co-owner:
______________________________________________________
Address (if different):
_____________________________________________________
City: _____________________________
State: ______________ Zip Code:_________
Boat Type: _________________________
Manufacturer: ________________________
Boat size (LOA): ___________ Boat Name:
___________________________________
Marina: __________________________ Dock &
Slip Number: ___________________
Paid Full Year’s Dues $ 120.00
Accepted By: _____________________________
Paid Prorated Dues $ __________
Authorized By (Club officer) ___________________