Town of Middletown, RI - Application Form

Town of Middletown, RI

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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.

Application

Reference Number

QEHTJEGU

Application Status

Unknown

Application Phase

Other Public Access

Application Type

Mooring Permit

Permit Type

Application Comments

Applicant

First Name

Middle Name

Last Name

Suffix

Contact Information

Mailing Street

Mailing City

Mailing State

Mailing Zip

Home Phone

Home Phone (Winter)

Mobile Phone

Work Phone

Email Address

Additional Information

Emergency Contact Name

Emergency Contact Phone

Vessel

Size

Length (ft)

feet

inches

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

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