APPLICATION FOR A PERMANENT PENNSYLVANIA BOATING …

APPLICATION FOR A PERMANENT PENNSYLVANIA BOATING SAFETY EDUCATION CERTIFICATE

Please check the appropriate box and follow the instructions below.

TEMPORARY to PERMANENT ($10) ? To convert a temporary PFBC (PA Fish & Boat Commission) certificate to a permanent certificate, submit this form, a copy of your temporary certificate, and payment.

DUPLICATE or REPLACEMENT ($5) ? To apply for a duplicate or replacement PFBC certificate, submit this form and payment. (This selection is only for persons who have previously been issued permanent PFBC certificates).

OTHER CERTIFICATIONS ($10) ? To convert a U.S. Coast Guard Auxiliary, U.S. Power Squadron, or other course approved by the National Association of State Boating Law Administrators (NASBLA) to a PFBC Boating Safety Education Certificate, submit this form, your current certificate, and payment. Include a selfaddressed, stamped envelope if you want your current certificate returned.

Processing and delivery of permanent cards may take 30 to 40 days. Should you not receive a permanent card within that time frame, contact the PFBC immediately at 888-723-4741. Please note that temporary PFBC Boating Safety Education Certificates are valid for only 60 days from the date of issue.

PA Certificate No.

(Leave blank if not known)

#

NAME

Last:

MAILING ADDRESS

Street or P.O. Box No.

CITY/STATE/ZIP

City:

BIRTH DATE

MM/DD/YYYY

CURRENT INFORMATION (Please PRINT)

First:

Middle Initial:

State:

Zip Code:

DAYTIME

PHONE

(

)

-

PLEASE CHECK "" THE APPROPRIATE SELECTION IN EACH COLUMN

(choose only one each)

Hair Color

Eye Color

Gender

Brown

Brown

Male

Blond

Green

Female

Gray

Blue

Black

Gray

Red

Other

Other

Number of Certificates Ordered: ______________

Payment: $_______________ (Do Not Send Cash)

Check or Money Order #_______________________________ (Payable to PA Fish & Boat Commission)

Credit Card # _______________________________________________ Exp. Date (ex. 04/2017) _________________

(Discover / MasterCard / Visa)

Mail to:

PA Fish & Boat Commission Boating Safety Education PO Box 67000 Harrisburg, PA 17106-7000

I hereby certify, under penalty of law, that the foregoing information is true and correct to the best of my knowledge, information and belief. I understand that submission of false information in connection with this official application may be subject to criminal penalties under 18 Pa. C.S. Ch. 49 and 30 PA. C.S. Ch. 9.

___________________________________________________________________________________ Applicant's Signature or Parental Signature if Applicant is Younger than 18 Years of Age

Rev: 6.2017

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