Marina Wait List Application

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MARINA WAIT LIST APPLICATION

Please use the form below to place your name on the Town of Brookhaven’s Marina Wait List.

A Non-Refundable Administrative Fee of $25 Per Marina is Required.

The available Marinas are:

Mount Sinai
Port Jefferson
Corey Creek
Forge River

You must be a Resident of the Town of Brookhaven to be Placed on the Marina Wait List.

Please contact our Town Clerk's Office for more information at 631-451-9101.

MARINA SELECTION(S)

Marina – multiple marinas may be selected*

Mount SinaiPort JeffersonCorey CreekForge River

BOAT OWNER'S INFORMATION

First Name*

Last Name*

Address*

City*

State*

Zip*

Different Mailing Address?

Primary Phone Number*

###-###-####

Secondary Phone Number

###-###-####

Email Address*

A receipt for this transaction and Town correspondence will be sent to this email address

Date of Birth*

You must be 16 years or older to apply

I hereby acknowledge that I must notify the Town Clerk’s office in writing of changes to my contact information, including my phone number, address, email*

By entering my full name in the box below, I attest, under penalty of perjury, that the information provided on the within Application to be placed on the Marina Wait List is true, that I am the person whose name and information appears on the within form. I further acknowledge that my electronic signature is the legally binding equivalent to my handwritten signature.*

please enter your full name

BOAT INFORMATION

Length of Boat*

Please note: Boats more than 40 feet in length cannot be accommodated.

Width of Boat*

PAYMENT INFORMATION

Address On File with Your Credit Card Company*

Billing Zip Code*

Credit Card*

Name on Credit Card*

Credit Card Number*

Credit Card CVV2 Verification Code*

Expiration*

Prove You Are a Human*

I acknowledge that I will incur a Convenience Fee of 2.35% of my order total with a minimum fee of $1.50*

I acknowledge that if I dispute the charge on my credit/debit card, I will incur a $75.00 Administrative Fee.*

Subtotal:

Credit Card Convenience Fee:

Total Cost:

Subtotal

Credit Card Convenience Fee

Total Cost

Date and Time

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