BH-RRF-001
Plaquemines Parish Government Boat Harbors & Shipyards Department Rental Release Form
Buras Venice Pointe a la Hache Empire Empire Shipyard
DATE: ___________________________
I hereby cancel the rental agreement of the following slip:
PIER #: ____________ SLIP #: _____________ ACCOUNT #:_____________________________ PERSONAL INFORMATION:
OWNER’S NAME: ____________________________________________________ CO-OWNER: ______________________________________________ PHYSICAL ADDRESS: ___________________________________________________________________________________________________________ CITY: ____________________________________________________________STATE:____________________________ ZIP:_______________________ MAILING ADDRESS (IF DIFFERENT FROM ABOVE): ______________________________________________________________________________ CITY: ____________________________________________________________STATE:____________________________ ZIP:_______________________ DRIVER’S LICENSE #: __________________________________________________
OTHER INFORMATION: _________________________________________________________________________________________________________ ___________________________________________________________ Date: _____________ Time: _________________ Renter’s Signature FOR OFFICE USE ONLY: RECEIVED FROM: _______________________________________________________________ RECEIVED BY: _______________________________________________ DATE: _______________________________________