Member Change Request (Change Member, Boat &/or Boating Services Information)

This form is to be completed by the person in whose name the AYC membership is heldto notify AYC of any changes to: Member; Boat;and/or Boating Servicesinformation currently on file with AYC. Please complete only the items you want to change and return to the AYC Office. Your completed form may be hand-delivered to the AYC Office, e-mailed copyto , or faxed to 902.477-0148.

Member Name: ______Current AYC Member #: ______

Effective Date of Requested Change: ______

Note (optional): ______

______

MEMBER INFORMATION
Change From (Remove) / Change To (Add)
Change of Member Status:
Senior35, Senior 30, Senior 25, Intermediate, Junior, Social, Outport, Affiliate, Associate
Associate Name
Associate Relationship To Member
Associate Gender
Associate Birth Year
Address (please include):
Street
City
Province
Postal Code
Phone (home)
Phone (work)
Phone (cell)
E-Mail 1 (Primary)
E-Mail 2 (Alternate for Member, or for Associate)
Emergency Contact Name
Emergency Contact Relationship to Member
Emergency Contact Phone (home)
Emergency Contact Phone (work)
Emergency Contact Phone (cell)
Billing Option:
Auto Billing, Payment Plan
Resignation: Please state Effective Date and Reason
BOAT INFORMATION (FOR SENIOR, LIFE & INTERMEDIATE MEMBERS ONLY):
I currently have ______(insert number) Boat(s) registered at AYC.
Boat Name(s): ______
□ I am ADDING a Boat
Boat Name
Registered Boat Owner
Design / □ Power / □ Sail
Length / Width / Draft / Weight
□ I am DELETING a Boat
Boat Name
□ I am CHANGING INFORMATION on a Boat I already have registered at AYC
Boat Name
Registered Boat Owner
BOAT SERVICES INFORMATION (FOR SENIOR, LIFE & INTERMEDIATE MEMBERS ONLY):
Please place a check mark (√) in all boxes that apply; indicate bothChange From (Remove) and Change To (Add) service you wish to have going forward (VERY IMPORTANT - this section will be used for invoicing.)
CHANGE(S) APPLY TO - BOAT NAME: ______
Change From (Remove) / Change To (Add)
Storage / Spar Storage
Storage Locker
Trailer
Cradle
Winter / No Storage
Dry Winter Storage
Wet Winter Storage
Summer / Mooring
Marina
Launch/Haul
Power (Summer) / None
15 amp
30 amp
50 amp
Power (Winter) Self-Identify Power Usage / None
Light (i.e. light bulb)
Moderate (i.e. heater)
Heavy (i.e. heater & Appliances / Watts:
Heater Wattage:
Appliances (specify):

*Signature: Date:______

* If you submit this form electronically no signature is required. By submitting this form electronically, you agree that you are electronically signing the form.

Page 1 of 2 Date: October 22, 2016