Operator Resume

Operators Resume of Experience & Medical History

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* Indicates required field

Name of Operator *

Date of Birth *

Address *

Married? *

Homeowner? *

City *

State *

Zip *

Phone # *

Email *

Employer *

Drivers License Number *

State *

Occupation *

Licensed Captain? *

Tonnage *

# of Years Licensed *

Please list all marine incidents you have been involved with; including vessels damaged or passengers, crew or other third parties injured while you were acting as captain in the past five years (If none, write “None”): *

Please list all automobile infractions you have been involved with; including accidents, tickets and restrictions within the past three years (If none, write “None”): *

Have you ever been convicted of a felony? *

If yes, please advise date, the event and penalty: *

Have you undergone surgery in the past five years? *

If yes, please advise date and type of surgery: *

Have you been injured on the job in the past? *

If yes, please advise date of injury and disposition of claim: *

List all marine insurance claims and/or prior marine loss history in past 5 years (If none, write “None”): *

Prior boats you have OWNED and/or OPERATED: COMPLETE ALL CATEGORIES

Boat #1:

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #2 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #3 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #4 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #5 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #6 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #7 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #8 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #9 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Boat #10 (if necessary)

Boat Status *

Manufacturer *

Length *

# Years *

Vessel Use *

Other *

I HEREBY AFFIRM THAT ALL STATEMENTS MADE HEREIN HAVE BEEN ANSWERED TO THE BEST OF MY ABILITY AND ARE TRUE.

Name of person completing *

Date *

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Operator Resume

Operators Resume of Experience & Medical History

You may also Download and Fill Up this form offline

Boat #1:

Boat #2 (if necessary)

Boat #3 (if necessary)

Boat #4 (if necessary)

Boat #5 (if necessary)

Boat #6 (if necessary)

Boat #7 (if necessary)

Boat #8 (if necessary)

Boat #9 (if necessary)

Boat #10 (if necessary)

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Operator Resume

Operators Resume of Experience & Medical History

You may also Download and Fill Up this form offline

​Boat #1:

Boat #2 (if necessary)

Boat #3 (if necessary)

Boat #4 (if necessary)

Boat #5 (if necessary)

Boat #6 (if necessary)

Boat #7 (if necessary)

Boat #8 (if necessary)

Boat #9 (if necessary)

Boat #10 (if necessary)

Navigation

Connect With Us

Share This Page

Contact Us

Location

Boat #1: