REMITTANCE by hcj

VIEWS: 111 PAGES: 2

									                                                                                    MSF 3233 09/09


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 A PPLICATION FORM IN CAPITAL LETTE RS AND SEND ORIGINAL TO THE
        ADDRESS PROVIDE D, ALONG WITH A COPY OF T HE VESSELS BLUE CARD
       ILLEGIBLE OR INCOMPLETE APPLICATION FORM S 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 (Y our Company Name)
Address of Applicant (Certificate return address)




Post Code
Country


Title (Mr, Mrs, Capt)
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)                     Cheque    /   Bank Transfer   /   MCA Account
MCA Account Number (if applicable)
                                                                              MSF 3233 09/09

                  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

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

								
To top