Official number	Ship’s name

Changed Particulars

Relevant role to be changed: Owner Agent

Change of name(s)

Former name - individual/company (as per ASIC)	Present name

Change of address

Former address	Present address The address must be: for an individual - residential address; for a company - registered office address; for a statutory body or foreign company - principal place of business

New nationality (if applicable)

*Contact telephone number	*Email address (if any)

Signatures

If the owner 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.

Date	Place

Signature(s) of owner	Signature of witness
Name of witness
Signature of agent (if agent is not the owner)	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