Particulars of ship

Ship’s name	Hull identification number*	Type of ship

Build	Stem	Stern
Rigging	Number of masts	Principal material of construction
Length	Method of propulsion	Port where usually berthed or moored

Particulars of applicant

Full name	Address (see note 1)

Nationality	Basis for nationality claim	Number of shares and date of purchase (see note 2)	(see note 3)	(see note 4)

/ /

*Contact telephone number	*Email address (if any)

Signature

I/We hereby being the owner, operator or agent of the unregistered ship described above and being an Australian national or a resident of Australia, hereby apply for the grant of a Certificate of Entitlement to Fly the National Flag and Red Ensign.

Date	Place

Signature of buyer	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

NOTE:

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

Nationality - If a body corporate, the country in which incorporated

Basis for nationality claim - birth or naturalisation

Number of shares - indicate if shares are jointly owned. There are a total of 64 shares in a ship.