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| Date plan filed: | / | / 2000 | |
| Departure date: | ETD: | Arrival date: | ETA: |
| Planned course | |||
| Number of persons | [ ] | ||
| Name: | Name: | ||
| Name: | Name: | ||
| Name: | Name: | ||
| Pets: [ } | Cat [ ] | Dog [ ] | |
| Return date: | Return ETD: | Return date: | Return ETA: |
| Shore contact person | Name | Phone | Cellular |
| Vessel Identification | Name | ||
| Vessel license or | Registration numbers: | ||
| Home Port: | |||
| Captain's Name: | |||
| Vessel type (check one): | sail [ ] | power [ ] | |
| Make: | Model: | ||
| Vessel type (check one): | sail [ ] | power [ ] | |
| Make: | Model: | [ ] Feet | |
| Colour of Hull: | Colour of Deck: | Cabin: | Canvas: |
| Type of Engine(s): | Gas [ ] | Diesel [ ] | |
| Distinguishing features | Sail # | ||
| Radios, monitored: | VHF channels | SSB | Cellular |
| Life rafts | make: | colour: | ID # |
| Dinghy | make: | colour: | ID # |
| Safety equipment | lifejackets [ ] | flares [ ] | EPIRB |
| Your Boats Photo (attach to back if no space) |
Your Boat Photo (attach to back if no space) |