Date                                                                

Name                                                                                                                          

Address                                                                                                                      

City                                                      State                                                               

Home Phone Number               ______Work Phone Number___                     _____ 

E-Mail Address                                                                                                           

Date of Birth__________________Are you a first time racer?                        

                        Boat Information

Name of Boat                                                                                                              

Boat Hull                                                          Boat Number                                      

Year of  Hull                                         Engine                                                 

Type of Engine                                                 Year of Engine             

Drivers Name                                                  

Owners Name                                     

Class                                                   

                        Payment

Registration Fee Paid                                                    Chk#                                                                                                               

Cash    _________                                                   Initials of officer