Canal Boat Certification Application Form

Name of contact:                                                                                                                       

Address:                                                                                                                                    

Phone: _________________fax: ________________   email:                                                 

Organization represented:                                                                                                         

Name of boat to be certified:                                                                                                      

If existing boat, date boat went into operation:                                                                           

If new boat, date operation is to begin:                                                                                       

Name(s) of designers and primary fabricator(s) of boat:                                                          

                                                                                                                                                   

                                                                                                                                                   

Name of owner of boat:                                                                                                             

Other Information:                                                                                                                    

                                                                                                                                                   

          Date:                               Signature of applicant:                                                                       

Owner hereby agrees to display certification plaque in prominent location on boat.

 Date: ____________ Signature of owner:                                                                                

Posted 4/8/07