Boat Registration and Driver Licence Application 2014 / 2015

The
The Boat
Boat Registrar
Registrar
NZ
Power
Boat
NZ Power Boat Association
Association
21
Hall
Road
21 Hall Road
Paengaroa
Paengaroa R
RD
D9
9
Te
Puke
3189
Te Puke 3189
Western
Western Bay
Bay of
of Plenty
Plenty
Boat Registration and Driver Licence Application 2014 / 2015
Section 1: To be completed in full for Boat Registration and Drivers Licence
FULL NAME OF DRIVER: (Mr., Mrs., Ms, Miss)
_________________________________________________________________________________________________________
FULL ADDRESS: _______________________________________________________________________________________________________
_____________________________________________________________________________
POSTCODE_________________
CLUB: _______________________________________________________________________________________________________________
Phone: Private _________________________
Mobile:______________________________
Bus: ______________________________
E-mail ________________________________________________________(please print clearly) Date of Birth:_______________________
SECTION 2: Drivers Licence Application. Complete in Full
New Application – (tick) NO

YES
 (If yes, a provisional licence will be issued)
Previous Licence (year) _______________ Number _________________
Type of Boat Which Licence Required – (tick)
Hydroplane

Racing Runabout

GP Hydroplane

Racing Outboard

Pleasure Craft (NZ)

Tunnel

SECTION 3: Boat Registration: (complete in Full) NOTE: One application per form please
Full name of Owner (if different from above) __________________________________________________________________
Boat Name:_________________________________________ If New Second Choice: ___________________________________
TYPE OF CRAFT: (Tick which applies)
Inboard Hydro

Inboard Racing Runabout

Outboard Hydro Tunnel

Outboard Racing Runabout

Make & Model of Motor:______________________________________________________________________________ _______
Motor CC Rating _________________________________ Class & Number ____________________________________ _______
Cockpit Cell No_______________________ Name of Builder_______________________________________________ ________
INDEMINITY FORM
In consideration of the acceptance of my entry, I hereby agree for myself, and my executors and assign not to make any Claim
against the New Zealand Power Boat Association Inc. and/or Club affiliated thereto and or/any member of the said Club or
Association in respect of any accident or damage occurring at any time when the regatta or competition is under the Control of the
New Zealand Power Boat Association Inc. and/or any Club whether caused by other competitors, their Representatives, their boats
or otherwise how so ever And I HEREBY FURTHER AGREE to indemnify the New Zealand Power Boat Association Inc. and/or Club
affiliated thereto and/or all members of the said Clubs against any loss, claims, Actions, costs or demands arising out of my
participation in the regatta.
Dated at ________________ this ______________ day of 20___ Signed by the said___________________
In the presence of __________________________Certified Correct.
Applicants Signature _____________________
The Boat Registrar
Plenty
TheBoat
BoatAssociation
Registrar
NZ
Power
NZ Power
Boat
Association
21 Hall Road
21 Hall Road
Paengaroa
RD9
Paengaroa
R
D9
Te Puke 3189
Te
Puke
3189
Western Bay of Plenty
Western Bay of
IMMERSION TEST CERTIFICATION FOR 2014 / 2015
This is to certify that: __________________________________
(name)
has successfully performed an immersion
test as required by the NZPBA Rules
on _________________________at _________________________________
(date)
(place)
This certificate is valid until 31 October 2015
Name of Instructor: ____________________________________
Signature: ________________________________________________
Date: ______________________________________________________
Organisation: ____________________________________________
Email address: __________________________________________
TO BE COMPLETED AND RETURNED TO BOAT REGISTRAR WITH LICENCE APPLICATION
The Boat Registrar
The Boat
Registrar
NZ Power
Boat
Association
NZ Power Boat Association
21 Hall Road
21 Hall Road
Paengaroa R D 9
Paengaroa R D 9
Te
3189
Te Puke
Puke 3189
Western
Bay of
ofPlenty
Plenty
Western Bay
REGISTRATION & LICENCE COSTS 2014 / 2015
NAME: ____________________________________________________________
BOAT NAME/s: _____________________________________________________
PLEASE SUBMIT TO BOAT REGISTRAR AT LEAST 14 DAYS BEFORE YOU INTEND TO RACE.
Racing Licence
$100-00 GST Inc
Boat Registration - paid before 1st December 2014
$100-00 GST Inc
Boat Registration – paid after 1st December 2014
$150-00 GST Inc
(If boat registration complies with Rule 62C or boat new to country)
Rule 62c
J Class Licence (Junior)
$23.00 GST Inc
Tick
TOTAL

$
Please attach your completed
Tick  Boat Registration and Drivers Licence Application
Tick  Medical Examination Form
Tick  Proof of current membership to an affiliated club for the ensuing year
Tick  Dunk Test Certification or Certificate (if applicable)
Tick  UIM Acknowledgment & Agreement Form (this form is now required to be completed annually)
Tick  UIM Therapeutic Use Exemptions Form (if applicable)
Method of Payment:
 Direct Credit to NZ Power Boat Association Account Number 03-1508-0003063-00 Please ensure
you use an appropriate reference when using the Direct Credit facility.

Date of Payment ________________

Enclosed Cheque/Cash
Post to:
The Boat Registrar
NZ Power Boat Association
21 Hall Road
Paengaroa R D 9
Te Puke 3189
Western Bay of Plenty
Shirley Wotton
NZPBA BOAT REGISTRAR
Ref: __________________________ YES/NO
YES/NO