Town of Middletown, RI - Application Form

Town of Middletown, RI

You are here:

Pre Application

Application Form

Application Completion

Instructions

Please submit this form using any of the contact methods provided below.

Instructions

1) The nearest sewage pump out facilities are located in the Stonebridge-Portsmouth Area. See map for details, at http://www.dem.ri.gov/maps/mapfile/pumpmap.pdf

2) In case of emergency contact the Middletown Harbor Master at 401-418-1096.

3) Rhode Island is designated as a "No Discharge State" by the US Environmental Protection Agency.

Provider Name

Town of Middletown

Provider Mailing Address

Attn: Lisa Sisson
123 Valley Road
Middletown, RI 02842

Provider Phone

401.846.1144 x7076

Provider FAX

401.846.0238

Application

Reference Number -

Application Type -

Application Phase -

Permit Type

Application Comments

Applicant

Last Name

First Name

Middle Name

Suffix

Contact Information

Mailing Street

Mailing City

Mailing State

Mailing Zip

Home Phone (Winter)

Home Phone

Work Phone

Mobile Phone

Email Address

Additional Information

Emergency Contact Name

Emergency Contact Phone

Vessel

Length (ft)

feet

inches

Vessel Photo(s)

(Maximum file size=4MB)

Wait List

Wait List Selection *

List Name

Mooring

Berth

Location

Location on Application

Latitude

Degrees

Minutes

Seconds

Get current location from browser, if possible. If you have an attached GPS device, those coordinates will be used. If you are using a cell phone, your position will be triangulated from the nearest cell towers. Otherwise, an estimated location will be used based on your IP address.

Longitude

Degrees

Minutes

Seconds

Acceptance


Terms and Conditions	All information I am providing is correct to the best of my knowledge. I have read and understand the Online Mooring User Terms and Conditions
Signature
Date

Your Ad Here...