FORM OF AUTHORITY

I, ____________________________________

of Boat Name:_________________________________________,

Boat Number:___________________,

hereby give authority for members of the National Bargee Travellers Association (NBTA) caseworkers to represent me and act on my behalf with regards to my dealings with the Canal and River Trust (CRT). In regards to these dealings, I hereby give consent for the NBTA Caseworkers Group to the disclosure of my records with CRT.

Signed:

____________________________

Dated: ______________________