Ready to book your marina pen?

Exmouth Marina Pens

BOOKING ENQUIRY FORM

To apply for a one our our pens please fill in the form.

Owners Details

Owner's Full Name *

Date of birth

Model

Company Name

ABN/ACN

Residential Address *

City

State

Postcode

Postal Address

Same as residential address

Different to residential address

Mailing Address

City

State

Postcode

Mobile/Telephone

Email

Contact Details

Skipper

Other

Contact Full Name

Date of birth

Model

Company Name

ABN/ACN

Residential Address

City

State

Postcode

Postal Address

Same as residential address

Different to residential address

Mailing Address

City

State

Postcode

Mobile/Telephone

Email

Compliance & Insurance Details

Insurance Broker/Company

Public Liability for $10 Million Policy No: *

Public Liability Expiry *

Policy or Certificate of Currency Supplied

Electrical Certificate

N/A or

Certificate Number

Electrical Certification Expiry

Gas Certificate

N/A. or

Certificate Number

Gas Certification Expiry

Copies of Certificates can be supplied?

Yes

No

Intended Term of Stay

3 months or more?

12 months or more?

month(s)

week(s)

day(s)

From Date *

Time in *

To Date *

Time out *

Facility Services

Power

Fuel

Water

Declaration

I authorise Exmouth Marina Pty Ltd to invoice me for the Vessel Fees which are payable in advance for the above nominated period of stay. I acknowledge that the account payment terms for all additional facility services are strictly 30 days from the date of invoice. I declare that I am aware of and will comply with the Terms and Conditions, Electrical, Gas and Insurance Requirements.

By checking this box you agree to all of above

Name *

Signature *

Todays Date *

Thank you for completing this form.

There was an error trying to send your form. Please try again later or contact us.

Once we receive we will get back to you with an update to your request.

Having trouble with our form?
Below is the link to download an alternative form.

DOWNLOAD OUR FORM

Our pen details

Here are our pens, with sizes and numbers

Ready to book your marina pen?

Exmouth Marina Pens

BOOKING ENQUIRY FORM

Owners Details

Contact Details

Invoiced to:

Vessel Details:

Compliance & Insurance Details

Intended Term of Stay

Facility Services

Declaration

Our pen details

Need help, get in contact