Name of Sailor *

First Name

Last Name

Sailor's Date of Birth *

Must be between 9 and 14 years of age.

MM

DD

YYYY

Name of Parent/Legal Guardian *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Sailor's Home Address *

Home address - No P.O. Box

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Primary Wage Earner *

First Name

Last Name

Work Phone *

(###)

###

####

Name of Secondary Wage Earner *

If none, put "NA"

First Name

Last Name

Work Phone

(###)

###

####

Financial Support *

Do you receive financial aid or government support from any other source(s)?

Yes

No

I attest to and certify that all the information and statements made by me on this application are true and correct to the best of my knowledge. *

First Name

Last Name

Date *

MM

DD

YYYY