Transcription of CHECK ONE MISSISSIPPI MOTOR BOAT New Application ...
1 Home PhonePrevious OwnerOther PhoneMiddleDate of BirthE-MailLess than 16 $ to less than 26 ..$ feet to less than $ feet and $ $ ..$ $_____ MO $ _____ CASH $ _____CCK or MO # _____CC$_____Date Received_____Return Date_____CHECK ONEqNew ApplicationqTransferqRenewalqDuplicateMI SSISSIPPI MOTOR BOATREGISTRATION APPLICATIONFOR FASTER SERVICE RENEW AT:Any license agent location Call 1-800-5GO-HUNT 24 hours a day FOR THREE (3) YEARSMS Registration Number ALL SHADED AREAS MUSTBE COMPLETED SEE BACK FOR INSTRUCTIONS ALL BOATS MUSTHAVE A HULL IDENTIFICATION OR SERIAL not, boat must be inspected. Please call your localRegion Office for additional Built Prior To Nov. 1, 1972 MUST Give Serial Number:Boats Built After Nov. 1, 1972 MUST Give 12 DIGIT Hull #:Make of BoatYear of BoatPresent Registration Number on BoatFeet:Inches:HULL OF Powered Boat Boat Saltwater Fishing: qYes qNo Citizenship: qYes qNo OPTIONAL OUTBOARD MOTOR INFORMATIONCo-OwnerFirst Name:Middle Initial: Last Name:Date of Birth:Social Security or DL Number: MOTOR 1 (Serial Number)Horse PowerTrailer Serial NumberMake CHECK or money order payable to MS Dept.
2 Of wildlife , fisheries , and parks Boat Registration Div. 1505 Eastover Drive Jackson, MS 39211-6374 Signature Certifies OwnershipDateDETACH AND KEEP WITH VESSEL UNTIL CERTIFICATE NUMBER IS RECEIVEDName _____Address _____City _____State _____Zip Code _____Make of Boat _____HIN or SERIAL # _____I Hereby Certify on _____I made Application for certification of number for above described for 60 days of issue. Carry on board when the vessel is being PENALTY OF PERJURY THIS INFORMATION IS TRUE AND CORRECT. _____Signature of OwnerSIGNHERE* APPLICANT S SIGNATURE REQUIRED *(OVER) Fees Effective January 1, 2010 FOR OFFICE USENOTICE: Proof of MISSISSIPPI Sales Tax to accompany all new and used boats bought from an out-of-state or in-state dealer alongwith dealer s invoice. A copy of a notarized or witnessed bill of sale must accompany all applications if boat is purchased from anindividual.
3 If this boat has been registered in your name in another state, please send a copy of that registration in lieu of a bill of OFFICE USEM otor 1 (Manufacturer) MOTOR 2 (Manufacturer) MOTOR 2 (Serial Number)Horse PowerRevised 2-2012 LastFirst Name or Name of BusinessMailing AddressCityDriver s License # / Social Security # StateCountyZip CodeStateINSTRUCTIONS1. Type or print in ink, except the Owner of boat must sign this All shaded areas must be If vessel is presently numbered, enter number in space provided on If vessel is registered in your name, in another state, please send copy of registration from that state in lieu of a bill of saleReturn Application with personal CHECK , cashier s CHECK , or money order with the appropriate fee to: MISSISSIPPI department of wildlife , fisheries , and ParksBoat Registration Division1505 Eastover Drive Jackson, MS 39211-6374 FOR YOUR CONVENIENCE, YOU MAY USE THE AREA BELOWAS A VALID BILL OF SALE WHEN PROPERLY WITNESSED OR NOTARIZEDMake of BoatYear BuiltHull #Boat Registration #LengthBuyer: (Print)_____Seller: (Print)_____Co-Seller.
4 (Print)_____ _____ _____ _____ _____Last NameFirst NameInitialLast NameFirst NameInitialLast NameFirst NameInitialSeller s Street AddressSeller SignatureBuyer SignatureCo-Seller SignatureWitness SignatureCityStateDateDateDateDateZip CodeSELLER(S) CERTIFY THAT STATEMENTS PROVIDED ON THE FRONT OF THIS Application FOR CERTIFICATIONOF REGISTRATION ARE TRUE AND ACCURATE TO THE BEST OF SELLER(S) OF: _____ COUNTY OF: _____This day personally came and appeared before me, the undersigned stated that all of the matters,things and facts set forth are true and correct as therein TO AND SUBSCRIBED BEFORE ME, this the _____day of _____, 20_____ My Commission expires _____Notary PublicThis Stub is to serve as your receipt until you receive your Certificate of Number. This must be kept with the vessel and availablefor inspection by Law Enforcement Officers. Upon payment of fee this stub authorizes use of your vessel. Its validity may beverified at any time by Enforcement Officers.
5 Make CHECK or money order payable to the MISSISSIPPI department of wildlife , fisheries , and parks . Record your cashier s CHECK or money order number here _____Internet Boater Education Course $ Classroom Courses/Contact MDWFP Region Offices;Classes Available April-SeptemberCall 1-888-874-5785 to Subscribe to MISSISSIPPI Outdoors Magazine. (this number is for magazine subscription only)
