Australian Government - Australian Maritime Safety Authority

AMSA forms

IMPROVEMENT NOTICE DECLARATION – AMSA 809
Marine Safety (Domestic Commercial Vessel) National Law Act 2012, schedule 1 ("National Law") section 110
 
Notice number
Vessel name
Vessel Id
Declaration

Personnal Declaration:

I, make the following declaration as:
Title (Mr, Mrs, etc.)
Surname
Given names
Postal address
Town/suburb
State
Postcode
Country
OR

Company Declaration:

Title (Mr, Mrs, etc.)
Surname
Given names
Postal address
Town/suburb
State
Postcode
Country

Company or Business name
Trading Name
ACN
ABN

I have /
Pty Ltd has * actioned the following item(s) as required by Improvement Notice

under section 110 of the "National Law".

List item numbers:

I understand that a person who intentionally makes a false statement in a declaration is guilty of an offence under section 137.1 of the Criminal Code Act 1995.

Signature
Name

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

Date
*Strike through and initial selection that is not applicable
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
Email applications can be sent to: nlincidents@amsa.gov.au

Postal applications can be addressed to:

Australian Maritime Safety Authority
Attention: National Law Incidents
GPO Box 2181
Canberra ACT 2601
Australia
AMSA form: 809
Version: 1 7/18