Charter Captain Courses

NOW AT Charter Captain Courses DELAWARE Professional Captains Course TECHNICAL COLLEGE REGISTRATION FORM GEORGETOWN, DE

Read and Complete Registration Form. Sign Registration.

Name: First: Middle: Last:

Address:

City: State: Zip code

Citizenship: SS#:

Phone HOME: Work: Fax: Email:

Date of Birth: Male Female Single Married

How did you hear about Charter Captain Courses?

Boating Experience (years and vessel size):

If any of the following is answered yes – please send a separate letter with details (year, charges, outcome) DUI/DWI – Alcohol / Drugs: [ ] Yes [ ] NO Felony Arrest Record [ ] Yes [ ] NO Drivers License revoked Use of Narcotics: [ ] Yes [ ] NO or suspended [ ] Yes [ ] NO [ ] Master License Course [ ] OUPV(6 pack) [ ] Assistance Towing [ ] Sailing Endorsement $1200.00 $900.00 $75.00 $75.00 Bring note-taking materials. Casual dress. Balance of Tuition due first night of class. Please bring a Photo ID Charter Captain Courses will not be liable for failure to provide any of the training or equipment, or the delay in providing such, where failure or delay results from civil commotion, war, government regulations, unavoidable casualty, acts of God, weather or any other cause beyond the control of Charter Captain Courses. Charter Captain Courses does not discriminate on the basis of age, sex, religion, marital/family status, handicap, race or ethnic group. Registration Signature and Payment Authorization

Tuition Deposit (non refundable) $ 200.00 [ ] Check [ ] Money Order [ ] Credit Card I authorize the use of my credit card in the amount of $ ______Acct # ______Exp Date ______[ ] MasterCard [ ] VISA

Student Signature: Date:

Mail to: Charter Captain Courses - 22 Washington Street – Cambridge, Maryland 21613 410-228-0674 FAX410-221-0425