Australian Government - Australian Maritime Safety Authority
MISCELLANEOUS FORM – AMSA 758
Marine Safety (Domestic Commercial Vessel) National Law Act 2012
 


A. Applicant details
Title (Mr, Mrs, Dr, etc)
Surname
Given names
Trading Name
ACN
ABN
Street name and number
Town/suburb
State
Postcode
Country
Postal address ( Same as street address )
Town/suburb
State
Postcode
Country
Phone
Mobile
Email
B. Reason for notification
C. Documents attached
 
D. 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 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 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.
Signature
Name

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

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: Standards Secretariat
GPO Box 2181
Canberra ACT 2601
Australia
AMSA form: 758
Version: 1 7/18