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MI-104 - Marshall Islands Ship and Corporate Registry

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MI-104 - Marshall Islands Ship and Corporate Registry Powered By Docstoc
					                                            REPUBLIC OF THE MARSHALL ISLANDS
                                              OFFICE OF THE MARITIME ADMINISTRATOR
                                     APPLICATION FOR SHIP RADIO STATION LICENSE
                                                   ALL ITEMS MUST BE COMPLETED
Name of Vessel                                                                   Call Sign                    Official Number          Gross Tonnage

Licensee


1.    Name of Applicant
      Address: Street                                                             City                                             Country
2.    Owner of Vessel
3.    Agent or Managers        Name
                               Address
4.    Accounting Authority     Name
5.    Description of transmitting apparatus for which license is desired: (For GMDSS installations also see Section 7.)
                                         Manufacturer                              Type No.             Radiated          Frequency Range           Emission
                                                                                                        Power in
                                                                                                        Antenna
                                                                                                         (Watts)

Telephone

MF/HF

VHF              1

                 2

                 3

Radar            1

                 2

Satellite        1

                 2

                 3

EPIRB            1

                 2

SART             1

                 2

Onboard Portable

               VHF

               UHF

Aeronautical

Miscellaneous



6.    Description of receiving apparatus:
                                                               Manufacturer                                        Type No.                  Frequency Range

NAVTEX

GPS

Miscellaneous




Rev. 3/04                                                                     1 of 2                                                                     MI-104
7.      Description of GMDSS radio installation:
                                                   Manufacturer                      Type No.            Radiated         Frequency Range                 Emission
                                                                                                         Power in
                                                                                                         Antenna
                                                                                                          (Watts)

VHF radio telephony

VHF/DSC encoder

VHF/DSC watch receiver

MF radio telephony

MF/DSC encoder

MF/DSC watch receiver

MF/HF radio telephony

MF/HF/DSC encoder

MF/HF/DSC watch receiver

Direct printing radio telegraphy

INMARSAT S.E.S.

NAVTEX

EGC receiver

HF direct printing telegraphy

Satellite EPIRB

VHF EPIRB

Radar transponder

Portable two-way transceivers

Lifeboat VHF

UAIS

SSAS Fitted?       Yes      No

Miscellaneous




8.      Emergency power supply:                    Storage batteries   and/or          Generator

                                                                                                                                          No. of Emergency Lights
9.      Type of Inter-Communications System                                       Type of clock                                           in Radio room


10.     The application confirms that the ship radio station installation and electronic navigational equipment conform to current ITU Radio Regulations and current
        IMO/SOLAS requirements.




                                                                                                        Applicant – must correspond with item 1




                                                                                                                    Signature and Title




                                                                                                       Clearly Print or Type the Above Signature



Date:                                                          20


Rev. 3/04                                                                       2 of 2                                                                         MI-104

				
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