| Name of vessel's operator: |
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| Telephone Number: |
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| Name of Vessel: |
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| Registration No.: |
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Description of
Vessel:
Type:
Make:
Color of Hull:
Color of Trim:
Most distinguishing identifiable feature: |
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| Rafts/Dinghies: Number:________ Size:_______
Color:_______ |
| Radio: Type: __________________ Frequencies
Monitored: _______________ |
| Number of persons onboard: |
| Name: |
Age: |
Address & Telephone: |
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| Note: List additional passengers on back. |
| Engine Type:___________
H.P.:_______ Normal Fuel Supply (days):_______ |
| Survival equipment on board:
(check as appropriate) |
| Food for ________ days - Water for ________
days |
| Trip: |
| Date & Time of Departure: |
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| Departure From: |
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| Departure To: |
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| Expected to arrive
by:____________ In no case later than:_____________ |
| Additional information: |