For Budget Marine Only

Approved By: _________________________

Account Code: _________________________

This account only pertains to the
Terms: _________________________
Dutch St.Maarten - Budget Marine Store

Name of Individual: ____________________________________________________________________

Name of Boat: ____________________________________________________________________

Name of Company: ____________________________________________________________________

Telephone: __________________________ Cell: ___________________________________

Email: ____________________________________________________________________

Street Address: ____________________________________________________________________

City: ____________________________________________________________________

State: ____________________________________________________________________

Zip Code: ____________________________________________________________________

Country: ____________________________________________________________________

Captain/Owner (only if info is different than above) _____________________________________________

Address: _____________________________________________________________________

Phone: ________________________ Email: ______________________________________

Persons Authorized to purchase on the account:

1. ____________________________________ 4. ____________________________________
2. ____________________________________ 5. ____________________________________
3. ____________________________________ 6. ____________________________________

Certification for Tax Exemption:

I, ________________________________________________ hereby certify that I am not a resident of St.

Maarten and that the goods purchased are for export only.

Date: ___________________________ Signature: _______________________________________________