(Fill in using block capitals, highlight as necessary)

MEMBERSHIP REQUIRED

Retainer / Bronze / Silver / Gold  



PERSONAL DETAILS



TITLE: Mr / Mrs / Miss / Ms / Other: .....
SURNAME: ............
FORENAMES: ..........
ADDRESS: .............................. ...................................
POSTCODE: ............
TELEPHONE NO: ...........
EMAIL: ...............................  

If you are registering for Gold Membership, please tick one of the following:
User covered on any boat.
Vessel covered for all users.


VESSEL DETAILS



NAME OF CRAFT: ..........................
TYPE OF CRAFT (ie Cruiser, Narrow boat):................
REGISTRATION NO:................
LENGTH: ....  
WIDTH: .....
HEIGHT: ...... (meters / feet)
DISPLACEMENT: .........
WEIGHT (approx.): .........
HULL: Wood / Fiberglass / Steel  


ENGINE DETAILS

TYPE: Inboard / Outboard   
MAKE: ...................
ENGINE SIZE: ....... (cc / HP)
ENGINE NO: ............
ELECTRICAL SYSTEM: 12 Volt / 24 volt
FUEL: Petrol / Diesel / 2-stroke / Other: .....
MODIFICATIONS (if any): ....................... ...................................
REGISTERED MOORINGS (if any): ................... ...................................
Tel No: ..........  



PAYMENT DETAILS



Please choose your method of payment:
CHEQUE: Made payable to RCR Ltd.
CREDIT CARD: Mastercard / Eurocard / Visa / Delta,Switch

Card NO: ..............
Expiry Date: ........  
Issue NO: ...... (switch only)
Signature: ...............
Date: .................  



Send completed form to: 


River Canal Rescue
Freepost NAT11249
Stafford
Staffordshire
ST17 0BR
Refunds will be given at the discretion of the company management. The data protection act 1998 came into force on 1 March 2000 and requires us to obtain your consent to our using the information you provide. By completing this application form you give your consent. This information submitted will not be supplied to any third parties for financial gain or otherwise without your written consent.