Online Registration - Queenscliff Harbour

THIS AGREEMENT is made BETWEEN Queenscliff Harbour Pty Ltd, ACN 106 099 889 of 1 Harbour Street, Queenscliff VIC P: (03) 5258 5459 [email protected] (Supplier) And:

Applicant's Name *

First

Last

Owner's Name (if different from above) *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Alternative Phone

Email *

Emergency Contact

Name

First

Last

Phone

Vessel Details

Vessel Name and/or Registration Number *

Design *

Type of Vessel *

Year

LOA (Length overall) *

Beam *

metres

Draft *

metres

Dates requested and any other comments *

Agreement

Insurance *

I certify

I certify that I have a minimum of $10 million public liability insurance for the above vessel and a current certificate of currency is attached below.

Certificate of currency upload.

Click or drag a file to this area to upload.

PLEASE NOTE: Only JPG, PNG, GIF and PDF files up to 2Mb are allowed.

Execution of Agreement *

I Agree

As the customer I acknowledge that I have completed this scedule to the best of my knowledge and have read and agree to be bound by the Queenscliff Harbour Casual Berthing Terms and Conditions and , applicable at this date.