Signature of Owner: ______________________________________________________
Sail Number: ____________________________________________________________
Name of Yacht: __________________________________________________________
Make/Type: _____________________________________________________________
Owner/Skipper: __________________________________________________________
Address: _______________________________________________________________
City: __________________________________________________________________
State: _____________ Zip: _____________________________________
Phone: (H): ______________________ (O): _________________________
LMPHRF Rating: ______________ Certificate Date: _____________________
Member US Sailing: Yes:___________ No: _____________
Email Address:________________________________________