EPIRB Hire – Emergency Contact Form

Please complete the form if you have started a Hire of an EPIRB

Account No.(Required)

Please enter your Account No. given on your Hire Agreement Example: HET000

Contact Name(Required)

Please give the Name of Hirer given on the Hire Agreement

Contact Surname(Required)

Please give the Name of Hirer given on the Hire Agreement

Business/Company Name

Only required if your hire is under a business/company name

Hire Contract Number(Required)

Please enter the hire contract number given on your Hire Agreement. Example: 0000012345

EPIRB No.(Required)

This is itemised on your Hire Agreement and both the EPIRB and packaging is labelled. Example: EPIRB001

EPIRB HEX No.(Required)

Please enter the HEX No. given at the end of the Item Description on your Hire Agreement. Example: 1D0E6C1222FFBFF

Hire Start Date(Required)

Hire End Date(Required)

Where will the EPIRB be carried(Required)

Example: UK

Beacon Use(Required)

Please enter the activity that is requiring an emergency beacon

Additional Comments

Please enter any more information about you planned activities, for example cruising area, and any other information you think is relevant.

Your Contact Details

Prefix(Required)

First Name(Required)

Surname(Required)

Email(Required)

Confirm Email(Required)

Address Line 1(Required)

Address Line 2

Town/City(Required)

County(Required)

Post Code(Required)

Country(Required)

If other, please state:

Primary Phone No.(Required)

Secondary Phone No.

Emergency Contacts

Please give two contacts in case we need to give them to the emergency services.

Prefix(Required)

Contact #1 Name(Required)

Contact #1 Surname(Required)

Contact #1 Phone No.(Required)

Prefix(Required)

Contact #2 Name(Required)

Contact #2 Surname(Required)

Contact #2 Phone No.(Required)

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How I heard about you:(Required)

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