To be completed by the Registered Agent.

Official number	Ship’s name

Reason why new Registration Certificate is required

(If mislaid, lost or destroyed, describe the circumstances)

*Contact telephone number	*Email address (if any)

Signature

I hereby apply for the grant of a new Registration Certificate for the ship described above.

Date	Place

Signature of registered agent	Signature of witness
If the applicant 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

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