YOUR INFORMATIONName:* First Last Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone: *(Home)(Work)(Cell)Email:* BOAT INFORMATION Boat Name:*Harbor:*Choose One31st Street59th StreetBelmontBurnhamDiverseyDuSableJackson InnerJackson OuterMonroeMontroseAssignment* Boat Length:*(Feet)Boat Type*Choose One...PowerSailNumber of Tanks*Choose One....OneTwoThreeEstimated Size of Tank(s)*GallonsNumber of Fittings*OneTwoThreeFitting 1 Location*Choose OnePort-ForwardPort-AmidshipPort-AftStarboatd-ForwardStarboard-AmidshipStarboard-AftFitting 2 Location*Choose OnePort-ForwardPort-AmidshipPort-AftStarboatd-ForwardStarboard-AmidshipStarboard-AftFitting 3 Location*Choose OnePort-ForwardPort-AmidshipPort-AftStarboatd-ForwardStarboard-AmidshipStarboard-AftSERVICE REQUEST Requested Date* Actual date of service dependent on availability. Service available Monday thru Friday Only.$10.00 Short Notice Fee will be applied.$10.00 Short Notice Fee will be applied.Comments:PAYMENT INFORMATIONOn Call Service $25.00 per serviceMore than one pump-out fitting: $5.00 per fittingAdditional charge for greater than 50 gallons per tankMajor credit cards accepted with a $25.00 electronic transaction fee on charges greater than $1,000.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name By submitting this form, I hereby agree to abide, by the rules and regulations of the Chicago Park District governing the use of harbors, and also to abide by all ordinances of said Park District. I further agree that the Chicago Park District shall not be held liable for any loss or damage, by theft or otherwise, to my boat or property while using a harbor or occupying any stall and in consideration of the permit so issued to me I hereby release the Chicago Park District of any claim by me for aforesaid loss, damage, or theft. I authorize a representative of the Chicago Park District to board the above boat at all reasonable times for inspection to determine it's seaworthiness, safety, and compliance of all Park District rules and regulations including the prominent display of a proper decal and compliance with the anti-pollution regulations. Pumpout* Price: $25.00 Additional Fitting Charge* Price: $0.00 Today NumberServiceDateToday-MonthToday-DayService-MonthService-DayMonth-DifferenceDay-DiffernceDay-Difference-2Short Notice Fee Price: $10.00 Short Notice Fee Price: $10.00 Total $0.00 This iframe contains the logic required to handle AJAX powered Gravity Forms.