Extended Stay Permit Application Form

Applicant Details

Name of Applicant*

First

Last

Address*

Phone*

Emergency Contact Name*

First

Last

Emergency Contact Number*

Is Applicant Owner of Vessel?*

Yes
No

Owner’s Name*

First

Last

Owner's Mailing Address (if different from above)*

Owner's Telephone Number (if different from above)*

Vessel Details

Type of Vessel*

Ship
Tender

Ship Details

Name

Registration Number (if any)

Length Overall (feet)

Power

Motor
Sail

Hull Colour

Cabin Colour

Engine Type (inboard or outboard)

Inboard
Outboard

Is the Engine Functional?

Yes
No

Is the Ship Insured for Third Party Liability? (attach a copy of the insurance)

Yes
No

Attach Insurance Document

Accepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.

Fuel Capacity (ltrs)

Is the Ship Insured for Pollution Liability?

Yes
No

Is there a Holding Tank on Board?

Yes
No

Description of Holding Tank

Capacity of Holding Tank (ltrs)

Does the Ship Have an Approved Anchor Light?

Yes
No

Number of Extended Stay Months You Would Like to Apply For?

Tender Details

Name

First

Last

Registration Number (if any)

Length Overall (feet)

Type of Tender (Kayak, Run-about, etc)

Hull Colour

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Extended Stay

Permit Application – Nanaimo Marina

Applicant Details

Vessel Details

Ship Details

Tender Details