Form 740 | AMSA

A. Applicant details

Title (Mr, Mrs, etc.)

Surname

Given names

Street name and number

Town/suburb

State

Postcode

Country

Postal address ( Same as street address )

Town/suburb

State

Postcode

Country

Phone

Mobile

Email

Company or trading name

ABN

ACN

Surveyor ID

B. Change to accreditation

Change in place of employment

Change of address and / or contact details

Change of name or any other change that may result in confusion as to your identity

Membership of a professional association revoked, suspended or involuntarily cancelled

Other, please specify

Details of change

Supporting evidence attached

C. Applicant’s declaration and consent

I declare that:

To the best of my knowledge the information provided by me in this application (and any attachments I have included with this application) is true and correct.
I understand 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 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 consent to the Australian Maritime Safety Authority, as the National Regulator, making all reasonable enquiries to verify that the information provided by me in this application (and any attachments I have included with this application) is true and correct.
I understand and acknowledge that a person is guilty of an offence under section 137.1 of the Criminal Code Act 1995 if the person 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.

Signature

Name

Please use a BLACK pen and ensure your signature fits inside the signature box

Date

Where to lodge: Australian Maritime Safety Authority, Attention: Surveyor Accreditation, PO Box 16001
Collins Street West, Melbourne VIC 8007, Australia or by e-mail to: DCVsurvey@amsa.gov.au

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.

Australian Maritime Safety Authority

ABN: 65 377 938 320

Fee advice

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Transaction Reference Number (TRN)	Description	Amount
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	GST $	${AdviceGST}
	Total AUD GST $	${AdviceTotalcost}

This fee advice is valid until ${AdvicePaymentExpiry} and is applicable only for the application associated with this fee advice. The assessment of your application will only commence once we have received your payment and all supporting documents. This is a non-refundable application fee and covers all the services required to process your request, however it does not guarantee that your application will be successful.

Payment details

Methods of payment

Payment via internet

Payment via phone

Payment via post office

AMSA: https://payments.amsa.gov.au can accept VISA or Mastercard payments only.

BPAY: Contact your bank or financial institution to make this payment from your cheque and savings transaction accounts. More information at bpay.com.au.

PostBillpay: www.postbillpay.com.au can accept VISA, Mastercard or PayPal payments only.

13 18 16 (POSTbillpay) can accept VISA or Mastercard payments only.

BPAY via your financial institution can accept cheque and savings payments only.

Payment can be made at any Australian Post Office within Australia by cheque, cash, EFTPOS, VISA or Mastercard.

The post office will issue you a receipt.

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