Your full name: Your e-mail address:   Your telephone #:

Your Address: Street: City: Province or State: Zip or Code:

Sailing Certification: CYA Certified Power Squadron Certified  Other Please specify:

Have you previously owned your own sail boat?

Yes  If Yes please indicate for how long, when and where:

No   If No please tell us about your sailing and charter experience.

Personal Information:

Do you smoke?  Yes No     What is your favorite sport activity? 

Do you have pets?  Yes No    Do you cycle?  Yes No   

How many people including you in your household?      Ages?

How did you hear about us?