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CONTACT FORM

By filling out and submitting this form, LRSE can help you best determine your liferaft needs.

Please provide the following information:
Name:
Street address:
Address (cont.):
City:
State/Province:
Zip/Postal code:
Country:
Daytime Phone:
Evening Phone:
E-mail:
FAX:
 
 

Boat Description:

Power
Sail
Commercial
Other  

Boat Name:

Length of Boat:
Do You:

Race?   Cruise?    Fish?
If "fish" is checked, do you sell your catch?

Yes   No
Is your vessel

Documented    State Registered
Max. distance traveled offshore:

  miles
Do you carry a 406 EPIRB? Yes    No
Geographic area most operated in:
Max. Number of people aboard:
Avg. Number of people aboard:
Liferaft Stowage Preference: Cannister    Valise
If Cannister, do you need a deck-mount cradle? Yes   No
Do you need a hydrostatic release for your cradle? Yes   No
How did you hear about Life Raft & Survival Equipment?
Are you interested in purchasing any of the following safety equipment? EPIRB
Immersion Suit
Medical Kit
Flare Kit
Life Jackets
Floatation Clothing
M.O.B. Equipment
Sea Anchor or Drogue
Safety Harness
Tether
Waterproof Light
Any other comments or remarks?

  
  
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