Australian Government - Australian Maritime Safety Authority

AMSA forms

INFORMATION RELEASE AUTHORISATION – AMSA 664
Marine Safety (Domestic Commercial Vessel) National Law Act 2012, Schedule 1
 
Guidance on when to use this form
This form may be used by the owner of a domestic commercial vessel to authorise the release of vessel records to an accredited marine surveyor or vessel owner for the purposes of undertaking a vessel survey.
A. Owner details
Title (Mr, Mrs, etc.)
Surname
Given names
Organisation Name
ACN
ABN
Position held within organisation
Street name and number
Town/suburb
State
Postcode
Country
Postal address ( Same as street address )
Town/suburb
State
Postcode
Country
Phone
Mobile
Email

Authorisation declaration
  • I am an office holder or authorised person to act on behalf of the organisation listed above.
B. Vessel details
Vessel name
AMSA Unique vessel identifier
State vessel identifier – if known
C. Request
Name of the marine safety agency where your vessel's survey or inspection records were held:
Please provide the accredited surveyor listed below with the following documents for my above named vessel:
  • The last survey reports
  • **Stability calculations / book
  • Certificate of survey
  • **Vessel plans / drawings
    **Note: Where vessel plans/drawings or stability books are requested, the requestor must attach a Letter of Authorisation from the copyright holder. If you do not know the copyright holder\s in order to seek authorisation, once a document search has been conducted you will be advised of the copyright holder details listed on any documents located. A letter of authorisation will then be required to progress the application further.
  • Letter of Authorisation attached - Please use template available here
D. Accredited marine surveyor or vessel owner details
Title (Mr, Mrs, etc.)
Surname
Given names
Accredited marine surveyor number
Street name and number
Town/suburb
State
Postcode
Country
Phone
Mobile
Email
E. Owner’s declaration

I declare that:

  • I consent to my vessel's records being released to the accredited marine surveyor named in this form for the purposes of conducting a survey on my vessel.
  • To the best of my knowledge the information provided by me in this is true and correct.
  • I consent to the Australian Maritime Safety Authority, as the National Regulator, making all reasonable enquiries in order to verify that the information provided by me in this application (and any attachment I have included with this application) is true and correct.
  • I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask that I provide any information or document that the National Regulator reasonably considers necessary for consideration of this application.
  • I understand and acknowledge that the Australian Maritime Safety Authority, as the National Regulator, may ask another person to provide any information, document or agreement that the National Regulator reasonably considers necessary for consideration of this application.
  • I understand and acknowledge that a person commits an offence under section 137.1 of the Criminal Code Act 1995 if the person knowingly gives false or misleading information, or omits anything without which the information is misleading, to a Commonwealth entity, to a person who is exercising powers or performing functions under a law of the Commonwealth, or in compliance or purported compliance with a law of the Commonwealth.
Owners signature
Owners name
Date
Privacy Statement
The collection of information requested in this form is required or authorised by Schedule 1 of the Marine Safety (Domestic Commercial Vessel) National Law Act 2012 (the Act). It will be used for purposes related to the Act and may be provided to Commonwealth or State/Territory government agencies for the purposes of marine safety. Failure to provide the information may result in the transaction not being processed. To contact us, or for more information on how to access or correct your personal information, how to make a privacy complaint, or how your information may be used or disclosed for purposes beyond those described in this statement, visit www.amsa.gov.au/privacy.
How to lodge
You can email or post your application form to AMSA.
Email applications can be sent to: AMSAConnect@amsa.gov.au
Postal applications can be addressed to:
Australian Maritime Safety Authority
Attention: AMSA Connect
GPO Box 2181
Canberra ACT 2601
Australia
AMSA form: 664
Version: 3 5/23