Ship’s name

Particulars of charterer

Full name	Address (see note 1)	Nationality (see note 2)	Basis for nationality claim (see note 3)	Extent of charterer’s interest in the charter party	Period of charter party
Birth Naturalisation Incorporation	/64	From: / / To: / /
Birth Naturalisation Incorporation	/64	From: / / To: / /
Birth Naturalisation Incorporation	/64	From: / / To: / /
Birth Naturalisation Incorporation	/64	From: / / To: / /

Contact telephone number	*Email address (if any)

Declaration

I / We hereby declare that the charterer named above is in a position to control the exercise of the rights and powers of the charterers under the attached charter party.

Date	Place

Signature of charterer	Signature of witness
If the charterer 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

NOTES

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

Nationality - if a body corporate, the country in which incorporated.

Basis for nationality claim – birth or naturalisation.

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