By filling out and submitting this form, LRSE can help you best determine your liferaft needs. Please provide the following information:
Name:
Street address:
Address (cont.):
City:
State/Province:
Zip/Postal code:
Country:
Daytime Phone:
Evening Phone:
E-mail:
FAX:
Boat Description:	Power Sail Commercial Other
Boat Name:
Length of Boat:
Do You:	Race?   Cruise?    Fish?
If "fish" is checked, do you sell your catch?	Yes   No
Is your vessel	Documented    State Registered
Max. distance traveled offshore:	miles
Do you carry a 406 EPIRB?	Yes    No
Geographic area most operated in:
Max. Number of people aboard:
Avg. Number of people aboard:
Liferaft Stowage Preference:	Cannister    Valise
If Cannister, do you need a deck-mount cradle?	Yes   No
Do you need a hydrostatic release for your cradle?	Yes   No
How did you hear about Life Raft & Survival Equipment?
Are you interested in purchasing any of the following safety equipment?	EPIRB Immersion Suit Medical Kit Flare Kit Life Jackets Floatation Clothing M.O.B. Equipment Sea Anchor or Drogue Safety Harness Tether Waterproof Light
Any other comments or remarks?