Application for Provisional Registration Certificate - Australian ...

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