Please describe the vessel to be delivered as accurately as possible:
Vessel Owner: Vessel Name:
Owner's address:
Street:
State or Province: Zip or Postal Code:
Country:
Telephone Number: Fax: E-mail:
Vessel Country of Registry:
Choose one of the following options: Yacht Commercial Sail Power
Construction (wood, fiberglass, etc.:
When built: Where: By whom:
Years in current ownership:
Type of rig (if applicable): Sail area (if applicable):
Date of Vessel's last Survey:
Number of engines: Manufacturer(s):
Hours of operation since last rebuilt:
Type of generator (if applicable): Hours on generator operation since last rebuilt:
Check which of the following equipment is on board and FUNCTIONING PROPERLY:
Compass: Magnetic Gyro Fluxgate
Deviation Card: When Swung:
Depth Sounder: Manufacturer:
GPS: Manufacturer:
Radar: Manufacturer: Head up: N. up: Stabilized:
Loran C: Manufacturer:
VHF Radio: SSB: GMDSS: Short wave:
Bilge Pumps: Auto: Manual:
Life Rafts: How many? When last serviced:
Required Flares in date:
Required Safety equipment in date (fire extinguishers, etc.) Please List:
Please list all vessel deficiencies:
Please list all equipment needed for delivery but not currently on board:
I require the above vessel to be delivered from to .
It should leave on the (date) and arrive no later than (date) .
This delivery is or is not time sensitive.
For this delivery, which of the following is valid:
a. I require only a Captain.
b. I require a Captain and Engineer.
c. I require a Captain and all necessary crew.
