MILL CREEK PIER SLIP APPLICATION                                                Marina Use Only:
410-293-3731      410-293-3410 FAX                                                             Status: __________
                                                                                                                        Application #: _____
PRIVACY ACT INFORMATION
Authority:  5 USC 301, 44 USC 3101
Purpose: To obtain information on MWR patrons who apply for a slip at Mill Creek Pier, Naval Station Annapolis.
Usage: To maintain records by which slip applicants may be contacted for slip lottery or to effect payment of charges due.
Disclosure: Disclosure is voluntary; however, failure to do so may result in loss of privileges to sign a contract for a slip.

NAME:  _________________________________________________________________________________
                              Last                                             First                                             Middle
Address:   __________________________________________________________________________________

 ___________________________________________________________________________________

Social Security: ________________________________________

Home Phone:  (____)_____________    Work Phone: (____)__________    Mobile (____)___________

E-mail Address:  ______________________________________________________

STATUS:   (Please check only one status)   RANK / GRADE: _______________________

    o  1.  Active Duty Personnel
    o  2.  Delayed Entry Personnel / Midshipmen
    o  3.  Members of Reserve Components (Ready Reserve & National Guard on active duty / Reservists in Training)
    o  4.  Armed Forces Retirees
    o  5.  Former and / or surviving spouses and family members
    o  6.  DoD Civilian employees (APF and NAF) assigned to the USNA Complex
    o  7.  DoD Contractor working on the USNA Complex
    o  8.  Space “A” for authorized personnel not assigned to the USNA Complex

Boat Details:    Length _________________    Beam  _________________   Draft _________________

I understand that in the event my application is granted use of a slip at Mill Creek Pier, I am prepared to sign a contract and will abide by the terms and conditions set forth by Carr Creek Marina.  Failure on my part to do either requirement, will result in denial of this application.  Contract year runs 1 April to 31 March.

Applicant’s Signature:  ________________________________________________________________

Date of Application: ___________________________________________
                                           Month          Day                Year

For Carr Creek Marina: ________________________________________________________________

USNA KTN 1710/43(Rev.7-04)