BOAT AMERICA REGISTRATION
USCG AUXILIARY • FLOTILLA 72 • NORWALK CT
Name
*
First Name
Last Name
Course Start Date
*
-
Month
-
Day
Year
mm/dd/yyyy
Connecticut Conservation ID Number
*
GET YOURS AT: https://ct.aspirafocus.com/internetsales
Date of Birth
*
mm/dd/yyyy
Are You Under 17 Years of Age?
*
No
Yes
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State
Zip
Are You a Member of the USCG Auxiliary?
*
No
Yes (no fee required - get textbook from your home flotilla)
If "Yes", fill in your flotilla number:
000-00-00
How Did You Hear of this Course?
*
USCG Auxiliary Website
Overhead sign at Flotilla 72 Training Center
Rex/Cove Marina "Harbor Talk"
Word-of-Mouth
Paper Flyer Bulletin Board *
My School/Organization/Club *
Community Calendar *
Boat Show *
* Which one?
Which calendar, bulletin board, organization, boat show, etc?
Fee paid by:
*
PayPal.com/paypalme/flotilla72 [Enter STUDENT's name below the $ amount and notify flotilla72pe@gmail.com you've paid] - Note: If you make an error, just contact flotilla72pe@gmail.com rather than selecting "Request Refund"
Cash or Check [Pay to "USCGAUX72" and contact flotilla72pe@gmail.com for mailing]
N/A [USCG Auxiliary member]
Submit
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