MUST FOR OFFICE USE MS Registration Number Date …

1 Home PhonePrevious OwnerOther PhoneMiddleDate of BirthE-MailLess than 16 feet ..$ to less than 26 ..$ Number ..$ ONEoNew ApplicationoTransferoRenewaloDuplicate MS Registration NumberMI- ALL SHADED AREAS MUSTBE COMPLETED SEE BACK FOR INSTRUCTIONS ALL BOATS MUST HAVE A HULL IDENTIFICATION OR SERIAL not, boat must be inspected. Please call your local Regional OFFICE for additional Number or 12 Digit Hull #Make of BoatModel YearFeetInchesHULL MATERIALoFiberglassoAluminumoWoodoSteelo PlasticoRubber/Vinyl/CanvasoOtherPRIMARY OPERATIONoPleasureoRent or LeaseoCommercial FishingoOther Cml OperationoCml Passenger CarryoDealer or Mfr DemooAgencyoCharter FishingPROPULSIONoAir ThrustoManualoPropelleroSailoWater JetoOtherFUEL TYPEoGasolineoDieseloElectricoOtherTYPE OF VESSEL oOpen MotorboatoCabin MotorboatoAuxiliary SailoSail OnlyoPersonal WatercraftoHouse BoatSaltwater Fishing: qYes Citizenship: qYes qNoOPTIONAL INFORMATIONCo-Owner First NameMiddleLastDate of BirthDriver s License # or Social Security #Model YearHorse PowerMake 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 _____ Street Address _____ City _____State _____ Zip Code _____ HIN or Serial Number _____Make of Boat _____ Propulsion _____ Length of Boat _____I hereby certify on _____ , that I applied for certification of Number for above described boat. SIGN HERE* APPLICANT S SIGNATURE REQUIRED *FOR OFFICE USE Date Received: _____ Payment Type: _____ Payment Amount: $ _____Provide Proof of Mississippi Sales Tax to accompany all new and used boats purchased from an out-of-state dealer or in-state dealer along with dealer's invoice. Sales tax can be paid at your local tax collector. A copy of a notarized or witnessed bill of sale must accompany all applications, if boat is purchased from an individual. If this boat has been registered in your name in another state, provide a copy of that Registration in lieu of a bill of sale.

3 Must provide proof of last registered Serial NumberLastApplicant First NameMailing AddressCityDriver s License # or Social Security # StateCountyZip CodeState#Motor Serial Number26 feet and over .. $ ..$ oPaddlecraftoAir BoatoPontoon BoatENGINE DRIVEoInboardoOutboardoPod DriveoStern DriveoOtherMotor Serial NumberManufacturerModel YearHorse PowerPresent Registration # on BoatValid for 60 days of issue. Carry on board when the vessel is being PENALTY OF PERJURY THIS INFORMATION IS TRUE AND CORRECT. _____ Revised 09/2016 Signature of OwnerDate(OVER) By signing this application, I declare under penalties prescribed in the statutes of Mississippi, to the best of my knowledge and belief that I own the vessel described herein and that the description and all matters stated herein are true and ModeloOtheroInflatable BoatoRowboatMISSISSIPPI MOTOR BOATREGISTRATION APPLICATION Registration VALID FOR THREE (3) YEARS Individual Application or print in ink, except the of boat must sign this shaded areas must be vessel is presently numbered, enter Number in space provided on vessel is registered in your name in another state, please send copy of Registration from that state in lieu of a bill of Department of Wildlife, Fisheries, and Parks Boat 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 NOTARIZEDThis Stub is to serve as your receipt until you receive your Certificate of Number .

4 This must be kept with the vessel and available for inspection by Law Enforcement Officers. Upon payment of fee this stub authorizes use of your vessel. Its validity may be verified at any time by Law Enforcement Officers. Make check or money order payable to the Mississippi Department of Wildlife, Fisheries, and Parks. Record your check or money order Number here _____Internet Boater Education Course $ (Online Fee)Free 6-Hour 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)#All transfer and new boats are processed at MDWFP headquarters ONLY, address listed Application with personal check, cashier s check, or money order with the appropriate fee to the address listed (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_____ Notary Public My Commission expires _____ _____Seller SignatureDateCo-Seller SignatureDate_____ _____ _____Seller s Street Address_____ State _____Zip CodeCityBuyer: (Print)Seller: (Print)Co-Seller.

5 (Print)_____Last Name_____ Last Name_____Last Name_____ First Name_____ First Name_____First Name_____Initial_____Initial_____Initial Buyer SignatureDateWitness SignatureDateSerial Number or 12 Digit Hull ID #Present Registration #Feet,QFheVMake of BoatBoat ModelModel Year