SEE EXPLANATION ON THE REVERSE“IMMARBE”SEE EXPLANATION ON THE REVERSE

INTERNATIONAL MERCHANT MARINE REGISTRY OF BELIZE

REGISTRATION OF MERCHANT SHIPS ACT. 1989

PROVISIONAL PATENT OF NAVIGATION OF SHIPS

TO THE DESIGNATED OFFICE IN

THE NETHERLANDS # 14

  1. APPLICANT’S NAME:
  1. APPLICANT’S ADDRESS:
  1. NAME OF OWNERS:
  1. ADDRESS OF OWNERS:
  1. VESSEL’S MANAGER OR HOME PORT ADDRESS (including phone and fax numbers)
  1. NAME OF VESSEL 7. IMO NUMBER
  1. PREVIOUS NAME (IF ANY) 9. PREVIOUS NATIONALITY
  1. TYPE OF REGISTRATION REQUIRED (TICK AS APPROPRIATE)

PROVISIONALSTATUSPERMANENT STATUS SPECIAL FOR SCRAP PLEASURE YACHT or

non commercial craft

UNDER CONSTRUCTION DUAL (CHARTER IN) SPECIAL FOR DELIVERY

11- GENERAL DESCRIPTION OF THE VESSEL
TYPE OF VESSEL / MATERIAL OF HULL / GROSS TONNAGE / NET TONNAGE / UNDER DECK
NO. DECKS
/ NO. MASTS / NO. BRIDGES / NO. FUNNELS / NAME OF BUILDERS / YEAR BUILT
LENGTH
/ BREADTH / DEPTH / TYPE AND POWER OF ENGINE / NAME OF ENGINE MAKERS / SPEED
12- SPECIFICATION IN CASE OF FISHING VESSEL
SUB CATEGORY / AREA OF FISHING
(See codes on reverse) / TYPE OF FISHING GEAR
(See codes on reverse) / CATCH SPECIES
(See codes on reverse) / CARRYING CAPACITY
In cubic or metric tons
____FREEZER /REEFER
____FISH CARRIER
____FISHING FACTORY
____ONLY FISHING

13.DESCRIPTION OF RADIO EQUIPMENT (IN CASE OF VESSELS NOT REQUIRING GMDSS EQUIPMENT)

14. VESSELS EQUIPPED FOR GMDSS AREA A1 A1 + A2 A1 + A2 + A3 A1 + A2 + A3 + A4

15. ISM CODE CERIFICATION(when applicable) Document of Compliance (DOC) Safety Management Code (SMC)

16. AUTHORIZED ENTITY RESPONSIBLE FOR RADIO ACCOUNTS :

COMPLETE ADDRESS OF RESPONSIBLE
FOR RADIO ACCOUNTS :

17.NAME OF SHIPPING AGENT IN BELIZE: Morgan & Morgan (Belize) Trust Corporation

18. AFFIDAVIT

Pursuant to Sec. 7 (1),(2) and (3) of the registration of Merchant Ships Act, 1989/1996 I,

Authorized representative of the vessel ,declare that the above information is true and hereby undertake to deliver teh neccesary documents required to obtain full term registration, no later than on the expiration date of the Provisional Patent of Navigation.

Given this day of of the year Signed before me.

SIGNATURE OF APPLICANTSIGNATURE OF AGENT RECEIVING APPLICATION

FORM-AP (RS)