BSS Form

Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State

Postal Code

Email *

example@example.com

Phone Number *

Phone Number

Mobile Number

Phone Number

Boat Name *

Boat Length

CRT reg number

Please Fill in as much information as you can

Hull ID number (if present)

Year Built

Builder :Steel Work

Builder: Fit out

Previous Cert Number

Expiry Date

Engine: Make

Engine: Type

Engine: Fuel Used

Location of gas test point

Fire Extinguisher: Qty, Type & Rating

Gas Fridge: Make & Model

Gas Fridge: Flued

Yes No

Catalytic Heater: Make & model

Catalytic Heater: Flued

Yes No

Cooker/oven grill: make & model

Hob: make & model

Stove: make & model

Stove: fuel type

Water Heater, Instant type: make & model

Central Heating: make & model

Number of Berths

High Level Vents: number

High Level Vents: Type

Low Level Vents: number

Low Level Vents: Type

If you are not able to attend on the day of examination, a Calcutt Boats representative may be asked to assist the examiner; this will be charged at £55 per hour.

I have read and understood the terms above, issued by the BSS Examination Board of Canal and River Trust *

I understand that the fee for examination and certification is £200 for leisure craft and £230 for liveaboard or shared ownership craft. *

Signature

Clear

Boat Safety Scheme