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					MSF 3233 04/09

APPLICATION FOR A UNITED KINGDOM CERTIFICATE ATTESTING INSURANCE OR OTHER FINANCIAL SECURITY IS IN PLACE IN RESPECT OF CIVIL LIABILITY FOR BUNKER OIL POLLUTION DAMAGE 2001 & OIL POLLUTION DAMAGE 1992
   PLEASE REFER TO EXPLANATORY NOTES BEFORE COMPLETING THIS FORM PLEASE COMPLETE THIS APPLICATION FORM IN CAPITAL LETTERS AND SEND ORIGINAL TO THE ADDRESS PROVIDED, ALONG WITH A COPY OF THE VESSELS BLUE CARD ILLEGIBLE OR INCOMPLETE APPLICATION FORMS WILL BE IGNORED WITHOUT WARNING

VESSEL DETAILS (As per blue card) Vessel Name IMO Number Distinctive Numbers/Letters Port of Registry Flag State of Vessel Gross Tonnage (ITC 69) APPLICANT Name of Applicant (Your Company Name) Address of Applicant (Certificate return address)

Post Code Country Contact Name Telephone Number (including any area codes) E-mail Address TYPE OF APPLICATION (YES OR NO) BUNKER 2001 APPLICATION TANKER 1992 APPLICATION REMITTANCE Method of Payment (Please Circle) MCA Account Number (if applicable) Cheque / Bank Transfer / MCA Account

MSF 3233 04/09

REGISTERED OWNER (As per blue card / If different from applicant) Registered Owner (Registered Company Name) Address (Must be the same as blue card)

Post Code (Must be the same as blue card) Country (Must be the same as blue card) SECURITY DETAILS (Insurance / P&I club details) P&I Club / Insurance Company Name Address (Must be the same as blue card)

Post Code (Must be the same as blue card) DURATION OF SECURITY (As per blue card) (DD/MM/YYYY) FROM: TO: TYPE OF SECURITY (See explanatory notes)

DECLARATION PRINT NAME SIGNATURE STATUS/POSITION DATE OF APPLICATION (DD/MM/YYYY)

On completion of this form, a hard copy (with original signature) for each vessel must be sent to: Civil Liability Team 2/13 Maritime and Coastguard Agency 105 Commercial Road Southampton SO15 1EG United Kingdom …with a copy of the Blue Card issued by your insurer and payment