Date:

New Horizon Bass Anglers

Member & Boat Identification

Personal Information

Name:

Home Phone:

Address:

Work Phone:

City/State/Zip:

Fax Phone:

e-Mail Address:

Cell Phone:

Height:

Weight:

Eyes:

Hair:

Gender:

Male

Female

Additional Features (i.e beard, mustache):

Health Condition(s):

Emergency Contact:

Relationship:

Phone Number(s):

Boat & Tow Vehicle Information

Boat Manufacturer/Model:  ________________________________

Length:  __

Color(s):  ____________

Registration Number:  _______

State:  __

Engine Manufacturer:  _________________

Horsepower:  _

OB

IB

Tow Vehicle Make:  ______

Style:  ____________

Year:  _______

Color(s):  ____________________

License Number:  ____________

State:  _________

Do you have two-way communications capability on-board your boat?

Yes

No

Type:

Cellular Phone Number:  _______________________

VHF

CB

Number Years Boating Experience:

Boating Safety Course:

Yes

No

Picture Identification Information

A recent personal photo and if applicable a photo

Personal

of your boat must accompany this form

Boat

and be on file with the Tournament Director

Tow Vehicle