Name of Vessel

Official or Award Number:

Legal Owner

U.S. Coast Guard Certification #

Mailing Address

City

State & Zip Code

Port of Call

Bodies of water used in

Operator

License #

Residence Phone:

Business Phone:

Mailing Address:

City

State & Zip Code

Length

Beam

Draft

Light Displacement

Construction

Propulsion:
Sail Only (   )
Power Only (   )

Single Screw (   )
Twin Screw (   )

Engine Mfgr. & Type

Date Built:

Name Vessel Type or Class

Builder

Date of Last Safety Inspection:

Inspected By:

Date of Last Dry Dock Inspection:

Inspected By:

Describe any Significant Modifications to the Vessel or Her Equipment Since Last Inspection(s):

Registered Owner Address