Official number	Ship’s name

Particulars of registered agent

The Registered agent must be an individual or company who will be managing the day to day running of the ship.

Full name (including middle names/s)

Address

* Contact telephone number	*Email address (if any)

Signatures

Date	Place

Signature of owner(s)	Signature of witness
If the owner / agent is a corporation, the document may be formally executed under the corporate seal. Alternatively, an officer of the corporation may sign it, endorse it with a legible statement of his/her name and designation and have the signature witnessed.
Name of witness
Address of witness
Signature of agent (if agent is not the owner)

NOTES

The address must be: Residential address - for an individual; Principal place of business - for a company or statutory body

Except where indicated by * the collection of information requested in this form is either required or authorised by the Shipping Registration Act 1981 (the Act). It will be used for purposes related to the Act (including possible overseas disclosure) and will be available for public search in circumstances as the Act requires. It may be made available to government agencies for statistical and administrative purposes. Failure to provide the information will result in the transaction not being processed. To contact us, or for more information on how to access or correct your personal information or how to make a privacy complaint, visit www.amsa.gov.au/privacy-policy