BOATING COURSE REGISTRATION
PLEASE PRINT CAREFULLY 
(INFORMATION WILL BE USED FOR YOUR COMPLETION CERTIFICATE AND MAY BE FORWARDED TO A STATE AGENCY)

Date: ____________
Last Name: _______________________
First Name ________________________	Middle Initial _______
Street Address: __________________________________________
City: ______________	State: __________  Zip code:__________
County: _________________________
Phone No: _______________________
Email: ___________________________

State Required Info:
 Male     Female       Last 4 digits of SSN:__ __ __ __
Date of Birth:  ___mm ___ dd ___yy       Hair Color:__________     Eye Color________
State of Birth: _________________        Height:_____ft.  ______ in.

Servey
BOAT TYPE:		 None		 Outboard		 Inboard / Outboard	
 Inboard		 Sail   		 Personal Watercraft
BOAT LENGTH:	 Under 16 Ft.	 16 to 25 Ft.	 26 to 39 Ft.
			 40 to 54 Ft.	 55 Ft. and over
HORSEPOWER: _____________
BOATING EXPERIENCE: ______ Years
USE BOAT TRAILER:  Yes  No

HOW DID YOU LEARN ABOUT THIS COURSE?

NEWSPAPER AD    NEWSPAPER ARTICLE    SHOPPER    TV/CABLE   

 POSTER/FLYER    RADIO    MARINE DEALER     FRIEND    SCHOOL  

 INTERNET     INSURANCE CO.    BOAT SHOW    OTHER:________________