LICENSEE:

ADDRESS OF LICENSEE:

VESSEL INFORMATION:

VESSEL INSURANCE:


(Shall not be less than $250,000 single limit/$500,000 aggregate limit)


(Shall not be less than $250,000 single limit/$500,000 aggregate limit)

After submission of this form, we will be contacting you for confirmation and payment.

Executed under the seal this ___________________ day of _____________ 2015.

LICENSOR: FAN PIER DEVELOPMENT, LLC

By (Name, Title): ____________________________________

LICENSEE:

By: ____________________________________