The Lakeland Bassmasters

First Name:________________
Last name: ________________
(Name should appear as on your BASS Membership Card)
Street address ______________________
City:______________________________
ZIP Code: _________________________
Contact Numbers
Home: ______________________
Work: ______________________
Cell: ________________________
Emergency contact:_____________________
E-mail address: _______________________
BASS Member # ______________________

I will fish as a  Boater    Co-angler
BOATERS ONLY:
Boat:   Make_________________ Year __________  Size ________   Engine HP _____

Insurance carrier: ________________________
Policy expiration date _____________________

NOTE: BOATERS MUST CARRY $300,000 LIABILITY INSURANCE. Policy must be on file in order to fish as a boater.

Sponsored By: __________________________
Date:_________________________