Home Phone
Previous Owner
Other Phone
Middle
Date of Birth
E-Mail
Less than 16 feet ..........$10.20
16 to less than 26 .........$25.20
Dealer number ..............$40.20
CHECK ONE
o New Application
o Transfer
o Renewal
o Duplicate
MS Registration Number
MI-
• ALL SHADED AREAS MUST BE COMPLETED • SEE BACK FOR INSTRUCTIONS •
ALL BOATS MUST HAVE A HULL
IDENTIFICATION OR SERIAL NUMBER.
If not, boat must be inspected. Please call your
local Regional Office for additional information.
Serial Number or 12 Digit Hull I.D. #
Make of Boat
Model Year
Feet
Inches
HULL MATERIAL
o Fiberglass
o Aluminum
o Wood
o Steel
o Plastic
o Rubber/
Vinyl/Canvas
o Other
PRIMARY OPERATION
o Pleasure
o Rent or Lease
o Commercial Fishing
o Other Cml Operation
o Cml Passenger Carry
o Dealer or Mfr Demo
o Agency
o Charter Fishing
PROPULSION
o Air Thrust
o Manual
o Propeller
o Sail
o Water Jet
o Other
FUEL TYPE
o Gasoline
o Diesel
o Electric
o Other
TYPE OF VESSEL
o Open Motorboat
o Cabin Motorboat
o Auxiliary Sail
o Sail Only
o Personal Watercraft
o House Boat
Saltwater Fishing:
q
Yes
q
No
U.S. Citizenship:
q
Yes
q
No
OPTIONAL INFORMATION
Co-Owner First Name
Middle
Last
Date of Birth
Driver’s License # or Social Security #
Model Year
Horse Power
Make check or money order payable to MS Dept. of Wildlife, Fisheries, and Parks • Boat Registration Div.• 1505 Eastover Drive • Jackson, MS 39211-6374
Signature Certifies Ownership
Date
DETACH AND KEEP WITH VESSEL UNTIL CERTIFICATE NUMBER IS RECEIVED
Name ________________________________________________ Street Address ____________________________________________ City ________________________
State ___________________ Zip Code _____________________ HIN or Serial Number _____________________________________________________________
Make of Boat ______________________________________ Propulsion _________________________________________ Length of Boat ___________________________
I hereby certify on ______________________________ , that I applied for certification of number for above described boat.
SIGN HERE
* APPLICANT’S SIGNATURE REQUIRED *
FOR OFFICE USE
Date Received: ___________ Payment Type: __________ Payment Amount: $ _________
Provide Proof of Mississippi Sales Tax to accompany all new and used boats purchased from an out-of-state dealer or in-state dealer
along with dealer's invoice. Sales tax can be paid at your local tax collector. A copy of a notarized or witnessed bill of sale
must accompany all applications, if boat is purchased from an individual. If this boat has been registered in your name in
another state, provide a copy of that registration in lieu of a bill of sale. Must provide proof of last registered owner.
Manufacturer
Trailer Serial Number
Last
Applicant First Name
Mailing Address
City
Driver’s License # or Social Security #
D.L. State
County
Zip CodeState
#
Motor Serial Number
26 feet and over .......... $47.70
Duplicate ..........$7.70
o Paddlecraft
o Air Boat
o Pontoon Boat
ENGINE DRIVE
o Inboard
o Outboard
o Pod Drive
o Stern Drive
o Other
Motor Serial Number
Manufacturer
Model Year
Horse Power
Present Registration # on Boat
Valid for 60 days of issue. Carry on board when the vessel is being operated.
UNDER PENALTY OF PERJURY THIS INFORMATION IS TRUE AND CORRECT.
______________________________________________________________
Revised 09/2016
Signature of Owner
Date
(OVER)
By signing this application, I declare under penalties prescribed in the statutes of
Mississippi, to the best of my knowledge and belief that I own the vessel described
herein and that the description and all matters stated herein are true and correct.
Boat Model
o Other
o Inflatable Boat
o Rowboat
MISSISSIPPI MOTOR BOAT
REGISTRATION APPLICATION
5(*,675$7,219$/,')257+5((<($56
Individual$SSOLFDWLRQ
INSTRUCTIONS
1. Type or print in ink, except the signature.
2. Owner of boat must sign this application.
3. All shaded areas must be completed.
4. If vessel is presently numbered, enter number in space provided on front.
5. If vessel is registered in your name in another state, please send copy of registration from that state in lieu of a bill of sale.
Mississippi Department of Wildlife, Fisheries, and Parks Boat
Registration Division
1505 Eastover Drive • Jackson, MS 39211-6374
FOR YOUR CONVENIENCE, YOU MAY USE THE AREA BELOW
AS A VALID BILL OF SALE WHEN PROPERLY WITNESSED OR NOTARIZED
This Stub is to serve as your receipt until you receive your Certificate of Number. This must be kept with the vessel and available
for inspection by Law Enforcement Officers. Upon payment of fee this stub authorizes use of your vessel. Its validity may be
verified at any time by Law Enforcement Officers. Make check or money order payable to the Mississippi Department of Wildlife,
Fisheries, and Parks. Record your check or money order number here ____________________________
Internet Boater Education Course • www.mdwfp.com • $15.00 (Online Fee)
Free 6-Hour Classroom Courses/Contact MDWFP Region Offices;Classes Available April-September
Call 1-888-874-5785 to Subscribe to Mississippi Outdoors Magazine. (this number is for magazine subscription only)
#
All transfer and new boats are processed at MDWFP headquarters ONLY, address listed below.
Return Application with personal check, cashier’s check, or money order with the appropriate fee to the address listed below.
SELLER(S) CERTIFY THAT STATEMENTS PROVIDED ON THE FRONT OF THIS APPLICATION FOR CERTIFICATION
OF REGISTRATION ARE TRUE AND ACCURATE TO THE BEST OF SELLER(S) KNOWLEDGE.
STATE OF: _______________________ COUNTY OF: _______________________
This day personally came and appeared before me, the undersigned stated that all of the matters,
things and facts set forth are true and correct as therein stated.
SWORN TO AND SUBSCRIBED BEFORE ME, this the ______________day of _____________, 20_____
____________________________________________
Notary Public
My Commission expires __________________
__________________________________ ______ ________________________ _________
Seller Signature
Date
Co-Seller Signature
Date
__________________________________ ______ ________________________ _________
__________________________________
Seller’s Street Address
________________
_____
State
___________
Zip Code
City
Buyer: (Print)
Seller: (Print)
Co-Seller: (Print)
________________
Last Name
________________
Last Name
________________
Last Name
________________
First Name
______
__________
First
Name
______
__________
First
Name
________________
Initial
________________
Initial
________________
Initial
Buyer Signature
Date
Witness Signature
Date
Serial Number or 12 Digit Hull ID #
Present Registration #
Feet
Inches
Make of Boat
Boat Model
Model Year
