Australian Government - Australian Maritime Safety Authority

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NOTIFICATION OF A CHANGE OF CIRCUMSTANCE (GOVERNMENT SURVEYOR BECOMING PRIVATE) – AMSA 742
Marine Safety (Domestic Commercial Vessel) National Law Act 2012
Marine Safety (Domestic Commercial Vessel) National Law Regulation 2013
 
A. Applicant details
Title (Mr, Mrs, etc.)
Surname
Given names
Date of birth
Nationality
Place of birth (town, state, country)
Street name and number
Town/suburb
State
Postcode
Postal address ( Same as street address )
Town/suburb
State
Postcode
Phone
Mobile
Email
If you have a company relating to survey, or employed by such a company
Company or trading name
ABN
ACN
B. Professional referees
First referee
Title (Mr, Mrs, etc.)
Surname
Given names
Relationship
Length of relationship
Place of employment and position
Street name and number
Town/suburb
State
Postcode
Postal address ( Same as street address )
Town/suburb
State
Postcode
Phone
Mobile
Email
Second referee
Title (Mr, Mrs, etc.)
Surname
Given names
Relationship
Length of relationship
Place of employment and position
Street name and number
Town/suburb
State
Postcode
Postal address ( Same as street address )
Town/suburb
State
Postcode
Phone
Mobile
Email
C. Satisfaction of eligibility requirements

The following must be included with your application. Incomplete applications will not be accepted and will be returned.

    • under an ISO 9001:2008 accredited Quality Management System for marine surveying, or
    • equivalent management system; or
    • in accordance with Part 1 of the Marine Surveyors Accreditation Guidance Manual (e.g. by letter of undertaking)
    • quote for the insurance; or
    • if the policy is issued outside of Australia, a letter from the insurance broker for the policy confirming the policy
  • Tick relevant membership level:
    Other
  • Name of professional organisation
    Issue date (dd/mm/yyyy)
    Expiry date (dd/mm/yyyy)

  • Some examples of evidence of current professional membership may be but not limited to:

    • AIMS stamp showing membership level and expiry date
    • RINA letter confirming class of membership and expiry date
    • IIMS membership card
    • IMarEST membership card
    • Tax Invoice alone is not acceptable, you must obtain a written statement from the association

  • Some examples may include but not limited to:

    • Statement of continued professional development (CPD) from your professional association
      or
    • Copies of certificates relating to:
      • additional qualifications you may have attained
      • short courses/safety training
      • technical meetings/conferences/workshops
      • mentoring
      • writing publications (e.g., subscriptions to magazines)
      • webinars relevant to marine surveying
      • survey work outside of national law; or
      • surveys completed prior to the MARS system
    • certified copy of a document issued to you by an Australian government department or agency that provides proof of your identity (e.g., birth certificate, immigration papers, drivers licence, passport, etc.)
      or
    • certified copy of your foreign passport
D. Applicant's declaration and consent
  1. Have you ever held accreditation (however described) as a marine surveyor which has been suspended or revoked?
  2. Have you ever had membership of a professional association related to vessel building, vessel design, vessel engineering or vessel survey revoked, suspended or involuntary cancelled?
  3. Do you consent to Australian Maritime Safety Authority publishing your telephone number, email address and geographical areas in which you will conduct surveys in addition to your name and accredited categories on the Schedule of Accredited Marine Surveyors, which is available at www.amsa.gov.au?
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 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 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 attachments that 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.
  • I understand that failure to comply with a condition imposed on a category of accreditation (including the statutory conditions) for which I have applied may be grounds on which AMSA may vary, suspend or revoke the accreditation, issue an infringement notice or commence prosecution action.
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

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AMSA form: 742
Version: 1 4/19