This form is required with your purchase of a Class B AIS and must be completed before your order can be processed.
Please follow instructions and fill in the required fields, then press the "Submit" button at the bottom of the page. Alternately, you may print and fax or e-mail firstname.lastname@example.org the pdf version along with a copy of your MMSI registration. Our fax number is 860-701-3432.
Because each transponder can only be programmed once with your personal MMSI number, these units are NOT CANCELABLE or RETURNABLE after orders have been placed.