Write your US SAILING INTERNATIONAL PROFICIENCY CERTIFICATE membership # **APPLICATION** the photo **You must be a US Citizen to apply for this certificate** and clip HERE Name: Date: Address: Street City State Zip Phone: Email: US SAILING # (Must be current, if not, contact membership to renew) Logbook sticker #’s for: Basic Keelboat # _______ Basic Cruising # Bareboat Cruising # _______ We ask that you adhere to the following regarding pictures: 2x2 inches in size Taken within the past 6 months, showing current appearance Color or black and white Full face, front view with a plain white or off-white background Between 1 inch and 1 3/8 inches from the bottom of the chin to the top of the head Taken in normal street attire Uniforms should not be worn in photographs. If wearing head covering daily for religious or medical reasons include a statement explaining that. Do not wear a hat or headgear that obscures the hair or hairline. If you normally wear prescription glasses, a hearing device, wig or similar articles, they should be worn for your picture. Dark glasses or nonprescription glasses with tinted lenses are not acceptable unless you need them for medical reasons. A medical certificate may be required. If you are sending us a photo electronically for us to print, please email this document and image to email@example.com. International Proficiency Certificate 25.00 Member supplied photo 0.00 Member supplies digital image for US SAILING to print *$10.00 $______ Shipping and handling 5.00 Sub Total $______ RI sales tax (if applicapable) 7% $______ TOTAL DUE US SAILING $______ Enclosed is my check/money order payable to US SAILING or Charge my Visa MasterCard American Express Card No Expiration Date _____/_____ Signature Please mail to: US SAILING, POB 1260, Portsmouth RI 02871 or fax to 401-683-0840.