Form Dcr199-209 - Occoneechee State Park Marina Slip Rental Application
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1Occoneechee State Park Marina Slip Rental Application
Type of Slip Requested:
20’ w/ 20 amps elect.
20’ w/ 20 amps elect. Handicapped
30’ w/ 20 amps elect.
30’ w/ 20 and 30 amps elect.
either type of 30’ slip
Name:
________________________________________________________________
Address:
________________________________________________________________
________________________________________________________________
Phone:
Home: _____________________
Cell: ______________________________
Daytime: _______________________
Email:
_______________________________________________
Emergency Contact (in case your boat needs attention and we cannot contact you):
Name: _________________________________
Phone: _____________________________
Boat Information: Make/Type: __________________________________________________
Boat Name (if any): _____________________________________________________________
Length: _____ft.
Beam (widest point): _____ ft.
Engine(s): _____# _____ HP
Sewage: ____none
____ portable
____installed tank w/ _____ gallons capacity
Other information: __________________________________________________________________
Applicant Signature: ______________________________
Date: ___________________
……………………………………………………………………………………………………….
Deliver, mail, or fax application to:
Occoneechee State Park
1192 Occoneechee Park Road
Clarksville, VA 23927-9449
Fax: 434/374-9243
•
Persons applying for handicapped slips may be required to provide verification of status for applicant or
member of household
•
If application is accepted, applicant will be required to sign a rental agreement and full payment will be due
within 30 days of notification
•
Any false or misrepresented information on this application may be cause for denial of application or
cancellation of rental agreement
•
Full rules and rental procedures are available at Occoneechee State park
……………………………………………………………………………………………………………
Office Use Only
Slip Number:
Amount Paid:
Amount Due:
Date Paid:
Notification Date:
Staff:
(DCR199-209)(12/11)
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