Marina List Application
Donna Lent, Town Clerk TC-16 rev. 8/19
Patricia Ryan-Correa, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
Please place my name on the waiting list for the following:
North Shore South Shore
Mount Sinai Sandspit (Patchogue)
Port Jefferson Corey Creek (Blue Point)
Forge River (Mastic)
BOAT OWNER’S NAME (One name only): ____________________________________________________________________
ADDRESS OF PRIMARY RESIDENCE: ____________________________________________________________
__________________________________________________________________________________________________________________
MAILING ADDRESS: _________________________________________________________________________
__________________________________________________________________________________________________________________
HOME PHONE #: ______________________________ MOBILE PHONE #: ______________________________
EMAIL ADDRESS: ___________________________________________________________________________
DATE OF BIRTH: ______________________________
LENGTH OF BOAT: _____________________________ WIDTH OF BOAT: _____________________________
(Please note: Boats more than 40 feet in length cannot be accommodated)
______ I HEREBY ACKNOWLEDGE THAT I MUST NOTIFY THE TOWN CLERK’S OFFICE IN
Initials WRITING OF CHANGES TO MY CONTACT INFORMATION, INCLUDING MY PHONE
NUMBER, ADDRESS AND EMAIL ADDRESS.
_____________________________________ ________________________
SIGNATURE DATE
Payment may be made by check or money order payable to “Donna Lent, Brookhaven Town Clerk” through
the mail or by cash, check or credit/debit card in the office.
Return completed applications along with correct fee to: Brookhaven Town Clerk
One Independence Hill
Farmingville, NY 11738
For Office Use Only
Receipt #: Date:
A NON-REFUNDABLE ADMINISTRATIVE FEE OF
$25.00 PER MARINA IS REQUIRED.
