1625-0071 Response Template

1625-0071 BRPSD Response Template.docx

Boat Owner's Report - Possible Safety Defect

1625-0071 Response Template

OMB: 1625-0071

Document [docx]
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Edit Consumer Safety

red color - denotes required fields


First Name:

Shape1

Field 'First Name' is blank

Middle Initial:

Shape2


Last Name:

Shape3

Field 'Last Name' is blank

Phone:

Shape4

Field 'Phone' is blank

Office Phone:

Shape5


Address 1:

Shape6


Address 2:

Shape7


City:

Shape8


State:

Shape9


Zip:

Shape10 -

Shape11


Zip 'Zip' is invalid

Email:

Shape12

Field 'Email' is blankField 'Email' is invalid

Manufacturer Name:

Shape13


Model Year:

Shape14

Field 'Model Year' is invalid

Model Name:

Shape15


Hull Id Number:

Shape16

Field 'Hull Id Number' is blank

Length Feet:

Shape17


Length Inch:

Shape18


Model Type:

Shape19


Date Purchased:

Shape20

Shape21


Date Field 'Date Purchased' is invalid

Dealer’s Name and Address Info:

Shape22


Boat Condition:

Shape23


Boat Use:

Shape24


Is Engine Defect?

Shape25 Yes

Shape26 No


Field 'Is Engine Defect' is blank

Engine and Driver Manufacturer:

Shape27


Engine Model Year:

Shape28

Field 'Engine Model Year' is invalid

Engine Model Name:

Shape29


Fuel:

Shape30


Propulsion Type:

Shape31


Is Accident?

Shape32 Yes

Shape33 No


Field 'Is Accident' is blank

Fatalities:

Shape34


Injuries:

Shape35


Accident Date:

Shape36

Shape37


Date Field 'Accident Date' is invalid

Accident Location:

Shape38  


Names Of Deceased:

Shape39


Ages Of Deceased:

Shape40


Accident Description:

Shape41


Defect Information:

Shape42


Description:

Shape43


Shape44 Shape45 Shape46


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPJCappel
File Modified0000-00-00
File Created2021-02-03

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