Membership Application (To PRINT FROM HERE - Click FILE, upper left, Click PRINT)

Please print and complete form – then mail to address listed below:

Name of Primary Applicant: Name of Spouse/SO:

___________________________________________ ________________________________________

Birthday: (mm/dd)________________________ Birthday: _____________________________

Additional member(s) in household (under 18 only - over 18 must join separately): Birthday(s):

__________________________________ __________________________________

Street Address or PO Box: City, State, ZIP Code:

__________________________________ __________________________________

*Sharing Codes: Please place the following codes in the spaces provided below, indicating how you would like the following personal information shared with other members: N – No Sharing – Private S – Sharing permitted for club business only A – Allow sharing between ALL club members for social contact or club business

Phone Numbers (include area code) Sharing Code*: Phone Numbers: (include area code) Sharing Code*:

Home: _ ____________________(_______) Work: ____________________(_______)

Pager: _ ____________________(_______) Cell: ______________________(_______)

E-mail(s) (please print clearly) _______________________________________________________(_________)

Please note that E-mail is our primary method of distributing club information (social events, etc.)

Indicate type of water craft you own______________________________________ (This is a water-oriented Club - all crew are welcome, however, and any and all water craft** will meet our eligibility requirements (**any type boat, pool float, water wings, noodle, Styrofoam cup, etc. …).

Membership dues will be for one year from the time you sign up. You will receive a bill when your dues come up for renewal. Couple/family dues are based on only two adults over age 18, along with any number of children under 18, who are all living at the same address. Dues are as follows:

$24 – Single membership; Out of state membership (Single) is $12

$36 – Couple/Family membership; Out of state membership (Couple/Family) is $24

I am enclosing a check in the amount of $____________ made payable to the Pirates on the Water for a Single/Couple/Family membership (please circle which membership you are requesting).

Mail to: Pirates on the Water,

P O Box 378574

Key Largo, FL 33037

Each member is responsible for his/her own actions and behavior as well as that of their parakeet(s) (parakeets are children). Membership in the club does not give members the license to use Margaritaville or Jimmy Buffett's name, song titles, lyrics, names or businesses or other copyrighted or reserved material owned by Margaritaville or Jimmy Buffett.

Dues are not deductible as a charitable expense for federal income tax purposes.

Signature:___________________________________________ Date: __________________________

Logo at the top of this and images on this website are property of Pirates on the Water for used by permission.

We strongly support copyright law. If you wish to use any image shown, please contact the Captain.

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