Boat Membership Application Form

Last Name

Home Phone

Residential Address

Alternate Contact Person (such as next of kin)

First Name

Date of Birth

Mobile Phone (that will be carried on boat with you)

Postal Address

Phone Number For Alternate Contact Person

Holiday Address - fill this out if you maintain a holiday residence, caravan or utilise camping areas

Name of Boat

Call sign (alternative call sign if used)

Registration Number

Make and Model

Material (fibreglass, aluminium etc)

Boat Length

Type of Boat (centre console, half-cabin etc)

Colour

Engine (number, make, horsepower)

Fuel Capacity (litres)

Aux Motor Fitted?

Type of Radio Fitted

Upload a photo of your boat, if you have one

Photo

Trailer Rego

Vehicle Make

Vehicle Rego

Vehicle Colour

Launch Area (Jurien Bay Marina, Cervantes, Green Head etc)

Marina Pen Number

Any additional information that may be relevant

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