Application for Provisional Registration Certificate - Australian ...

APPLICATION FORPROVISIONAL REGISTRATION CERTIFICATEShipping Registration Act 1981Section 22, Regulation 15This application should be accompanied by:1. Application for Rgistration and relevant documents;2. The instrument (if any) by which ownership of the ship passed to the owner named in the application;3. If the application is signed by the master of the ship, documentary evidence of appointment and of authority to sign the application;4. The tonnage certificate (if any) that is in force in relation to the ship;5. If the ship has at any time been registered under the law of aforeign country, documentary evidence that:(a) the ship is no longer registered under the law of that country; or(b) steps have been taken, or are proposed to be taken, to close the registration of the ship under the law of that country on orbefore the grant of the provisional registration certificate.Identification of shipExisting name of shipParticulars of propulsionMethod of propulsion (eg. sail and motor, sail, motor)IMO numberHull IDPower transmission (eg. single screw, twin screw)Proposed name of ship (see notes)Estimated max. speedunder powerBrake powerCall signProposed home port (see notes)knbhp / kWIndicated powerShaft powerbhp / kWbhp / kWParticulars of shipComplete all information, if not applicable please enter N/ANo. of enginesType of engines and fuel (ie diesel, petrol)Type of shipBuild (eg. carvel, clinker, hard chine)Make of enginesModel of enginesStem (eg. raked, straight, curved, clipper)Stern (eg. transom, canoe, counter, tuck)No. of cylindersSerial No. of engine(s)Rigging (eg. cutter,ketch, sloop, schooner)Principal material of constructionNumber and type of boilers (include maker’s name and loaded pressure)Number of decksNumber of mastsNumber of bulkheadswatertight: non-watertight:Number of hulls*Estimated tonnageComplete if the ship is required by the Navigation Act 1912to have a Tonnage Certificate but has none.Gross tonnageRegistered tonnageLength overallMaximum breadth. metres . metresIdentity of the person who made these estimatesMoulded depth amidshipsTonnage length. metresAMSA 171 (3/14) Page 1 of 3

Previous registrationComplete if the ship has been previously registered in Australia or elsewhereYear registeredRegistered name of shipCountry Home port Official number of shipIf you are unable to supply any of the information in this section please give reasonsBuilding ParticularsName and address of builder Place of construction Year of completionBuilder’s identification of ship or ship’s nameIf you are unable to supply any of the information in this section please give reasonsParticulars of ownershipFull nameAddressNationalitybirth, naturalisationor corporationExtent ofinterest of the64 sharesApplicant’s telephone number and/or email address*Particulars of charterer Complete if the application depends on a demise charter to an Australian-based operatorFull nameAddressNationalitybirth, naturalisationor corporationExtent ofinterest of the64 sharesAMSA 171 (3/14) Page 2 of 3

Particulars of acquisition by the present ownerDate of acquisition Manner of acquisition Name of person or company from whom the ship was acquiredAddress of person or company from whom the ship was acquiredOccupation of the person from whom the ship was acquired ie sellerThe following documents are submitted with this applicationApplication for RegistrationDeclaration of Ownership and NationalityNotice of Appointment of Registered AgentProof of OwnershipEvidence of removal from a foreign register (if applicable)Persons authorised by the owner to be master during the currency of the provisional registration certificateName and address of masterCertificate of competency number(if required by the Navigation Act 1912)DeclarationI hereby apply for a provisional registration certificate for the ship detailed above.DatePlaceSignature of applicantIf the applicant is a corporation, the document may be formallyexecuted under the corporate seal. Alternatively, an officer of thecorporation may sign it, endorse it with a legible statement ofhis/her name and designation and have the signature witnessed.Signature of witnessName of witnessAddress of witnessExcept where indicated by * the information requested in this form is required by the Shipping Registration Act 1981. It will be usedfor the purposes of the Act and will be available for search. It may be made available to government agencies for statistical andadministrative purposes.AMSA 171 (3/14) Page 3 of 3