Boater Certification Card Request Form

Print and fill in the information requested in the form below. Send a check or money order for the appropriate amount and this completed form to the address below. Proof of successful completion of a NASBLA approved course may be required. If you completed the course with the Missouri State Water Patrol prior to 2011 or with the Missouri State Highway Patrol in 2011 or after, you may still need to provide proof. See the Boater Certification FAQ sheet for more information on card purchasing and replacement.

Card Cost: $15.00
Pay to the order of: Missouri State Highway Patrol

Mail this information to:

Missouri State Highway Patrol
Water Patrol Division
P.O Box 568
Jefferson City, MO 65102

Please Type or Print Clearly

Last Name_____________First Name_____________M.I._____

Street Address________________________________________

City_________________State__________Zip Code__________

DOB__________Gender________Check#__________________

Phone# (___) _____________

Course taught by what organization_______________

Course Location and Date__________________________________

Allow up to 30 days for processing of your application and return mail.