1A - Application for Vessel Registration



|[pic] |COOK ISLANDS |Ship Registration |

| |APPLICATION FOR VESSEL REGISTRATION, CALL SIGN AND OFFICIAL NUMBER |FORM 1A |

| | |v.10 |

PART 1 – GENERAL

| | | | | | |

| |NEW VESSEL NAME |PRESENT VESSEL NAME (if different |IMO NUMBER |PRESENT COUNTRY OF REGISTRY or NEW CONSTRUCTION | |

| | |from new name) | | | |

| |      |      |      |      | |

| | | |

| |VESSEL TYPE (e.g. cargo, |PRESENT CLASSIFICATION SOCIETY |INTENDED CLASSIFICATION |PROPOSED DATE OF REGISTRATION UNDER CI FLAG | |

| |fishing, passenger, tanker | |SOCIETY | | |

| |etc) | | | | |

| |      |      |      |      | |

| | | | | | |

PART 2 - CONSTRUCTION AND DIMENSION PARTICULARS

| | | | | |

| |NUMBER OF MASTS |NUMBER OF DECKS |BUILT BY |YEAR BUILT |PLACE BUILT |NUMBER and TYPE of ENGINES | |

| |      |      |      |      |      |      | |

| | | |

| |POWER (kW) |NAME OF ENGINE MANUFACTURER |HULL MATERIAL |PLACE AND DATE OF |AUTOMATED ENGINE ROOM | |

| | | | |CONVERSION (if applicable)| | |

| | | | | |YES: | | |

| |      |      |      |      |NO: | | |

| | | |

| |REGISTER DIMENSIONS IN METRES | |

| |(In accordance with the International Tonnage Convention, 1969) | |

| |LENGTH OVERALL |LENGTH |BREADTH |DEPTH | |

| |      |      |      |      | |

| | | |

| |GROSS TONNAGE |      |NET TONNAGE |      | |

| | | | | | |

PART 3 – OWNER OF THE SHIP

(If Owner does not have 100% interest in the vessel, attach schedule of interested shareholders)

|Enter here details of the company, or individual, who owns the vessel. |

|COMPANY NAME AND POSTAL ADDRESS |CONTACT DETAILS |

|      |Phone: |      |

| |Facsimile: |      |

|IMO COMPANY NUMBER |Mobile/24 hr: |      |

|      |E-mail: |      |

PART 4 – MANAGER and /or DECISION MAKER

Note: This information may need to be used for safety alerts, correspondence and billing for Annual Fees. It is important to ensure that the Registry is informed of any changes.

|I hereby accept the appointment as Manager and confirm that I have full authority to act on behalf of the Owners in relation to the above named ship.|

| |

| | | | |      | |

| |(Signature) | | |(Print Name) | |

| | | | |

|Date: |      | |      |

| | | |(Position in Management Organisation) |

|POSTAL ADDRESS and COMPANY NAME (if applicable) |CONTACT DETAILS |

|      |Phone: |      |

| |Facsimile: |      |

|IMO COMPANY NUMBER (if applicable) |Mobile/24 hr: |      |

|      |E-mail: |      |

PART 5 – RADIO ACCOUNTING AUTHORITY

| Enter the name of the accounting authority with which an accounting contract is held. The |Company Name |AAIC No. |

|authority will be responsible for all communication accounts. The authority must be an ITU |      |      |

|approved accounting authority | | |

PART 6 – RADIO STATION EQUIPMENT

(A copy of Radio Licence and Radio certificates

will be required to complete Provisional Registration)

|If the radio equipment described in the ship’s current radio licence and radio certificates has changed or the certificate is no longer available, |

|then a written notice advising of the changed equipment must be sent with this application (Form 5A). |

| |

PART 7 – EMERGENCY POSITION-INDICATING RADIO BEACON

| |

|Ensure the EPIRB is a 406 MHz beacon. The hexadecimal number must be programmed correctly bearing 518 (the Cook Islands prefix) followed by the beacon|

|serial number. This hexadecimal number must also be displayed on the outside of the EPIRB. |

| |

|Once your EPIRB has been re-programmed you must advise MCI of the new EPIRB hexadecimal and serial numbers. |

| |

|All Cook Islands Flagged Vessels that have an EPIRB are required to register with the Rescue Co-ordination Centre New Zealand (RCCNZ) on line at |

|.nz/406-Registration.aspx |

PART 8 – SAFE MANNING

(A copy of ship’s Minimum Safe Manning certificate

will be required to complete Provisional Registration)

| |

|If any changes in the vessel’s equipment, use or trading area have been made since the issue of the current safe manning certificate, a written |

|application must be sent with this application (Form 6) |

|Please insert INTENDED TRADING AREA(s):       |

|Vessel Certified for GMDSS |Yes |No |

|Vessel Certified for UMS (unattended Machinery Space Operations) |Yes |No |

PART 9 – INSURANCE / P&I

(Details of Insurance Company for P&I will be

required to complete Provisional Registration)

|P&I (Third Party Liability) |Phone: |      |

|Name and Address of Insurer | | |

|      |E-mail: |      |

| |Expiry date of| |

| |Policy |      |

|P&I (Crew) (if different from above) |Phone: |      |

|Name and Address of Insurer | | |

|      |E-mail: |      |

| |Expiry Date of| |

| |Policy |      |

PART 10 – MORTGAGE DATA

|NAME and POSTAL ADDRESSES OF |Phone: |      |

|MORTGAGEES | | |

|      |Fax: |      |

| |E-mail: |      |

PART 11 – DECLARATION OF ISM MANAGEMENT COMPANY

AND DESIGNATED PERSON (S)

Under the ISM Code, a Company must be declared to the Administration. In accordance with Section 1.1.2 of IMO Resolution A.741(18), the ISM code, “Company” means the Owner of a ship or any other organisation or person such as the Manager, or the Bareboat Charter, who has assumed the responsibility for operation of the ship from the Ship owner and who on assuming such responsibility has agreed to take over all the duties and responsibility imposed by the Code.

|COMPANY NAME AND POSTAL ADDRESS |CONTACT DETAILS |

|      |Phone: |      |

| |Facsimile: |      |

|IMO COMPANY NUMBER |Mobile/24 hr: |      |

|      |E-mail: |      |

Following person(s) has (have) been assigned pursuant to Cook Islands Maritime Regulation 1.07.3 and IMO Resolution A.7414 (18), Section 4, of the ISM Code, as the Designated Person(s) for the vessel in this application:

|Name |      |

|Position in the Company |      |

|24 h contact number |      |

|Mobile phone number |      |

|Name |      |

|Position in the Company |      |

|24 h contact number |      |

|Mobile phone number |      |

PART 12 – PARTICULARS OF DECLARANT

(If declarant is an authorised officer, attach authority/power of attorney)

|FULL NAME |TITLE |CITIZENSHIP |ADDRESS |

|      |      |      |      |

|PHONE |      |FAX |      |

|E-MAIL |      |

|THE DECLARANT IS THE : OWNER /OWNER’S AGENT/ OWNER’S OFFICER /ATTORNEY-IN FACT |

|IF OTHER , EXPLAIN HERE:      |

PART 13 – DECLARATION

| | | | | |

| |I, |      |hereby declare that, | |

| | (Full name) | |

| | | |

| |1. |I am the person referred to above in Part 12 and duly authorised to make this declaration. | |

| |2. |The Ownership in the ship is evidenced by a Bill of Sale/other document, the original/certified copy of which is attached. | |

| |3. |I agree to advise the Registrar of any change in “Designated Person(s)” or “ISM Management Company” in writing. | |

| |4. |I understand upon acceptance of this application by the Cook Islands Administration, I must take immediate steps towards deleting | |

| | |the vessel from its present flag of registry. | |

| |5. |Pending the effective date of a contract with a Maritime Cook Islands approved Accounting Authority responsibility for payment of | |

| | |accounts regarding correspondence using any radio service of the vessel will be assumed by the owner(s). | |

| |6. |I understand that the registration fees will be paid prior to registration. | |

| |7. |I understand and agree that P&I insurance cover for the vessel must be in place on the date of permanent registration. | |

| |8. |I agree that notwithstanding the issue of a certificate of provisional registration, I will ensure that all matters necessary to | |

| | |complete permanent registration (including registration of an international/foreign company) will be completed. | |

| |9. |That the information given in this and all supporting documents is, to the best of my knowledge and belief, true and correct. | |

| | | | |

| | |This Declaration shall be made before a Justice of the Peace, or a Commissioner for Oaths, Solicitor, Notary Public or the | |

| | |Registrar or Deputy Registrar of Ships of the Cook Islands Ships Registry or before any person authorised by law to administer | |

| | |oaths in the country where the declaration is made. | |

| | |Declared Before me:       (Name of witness) | |

| | | | | | | | |

| | |(1) | | |(2) | | |

| | |(Signature of Declarant) | |(Signature of Witness) | |

| | | | | | |

| | |      | |      | |

| | |(Date) | |(Occupation) | |

| | | | |      | |

| | | | |(Address) | |

| | | | | | |

| | | | |Stamp | |

|Documents to be attached in this Application |

|for the processing of ship’s PROVISIONAL Registration |

|Copy of Bill of Sale to present owner OR Builder’s Certificate (new construction only) | |

|Copy of Application to either register a Foreign Company OR incorporate a Cook Islands International Company | |

|Copy of confirmation (letter or email) from Classification society that they will issue certificates while vessel under | |

|Cook Islands Flag | |

|Copies of all vessel’s present certificates issued by current flag state and classification society | |

|Copy of schedule of interested shareholders (if applicable – see section 3) | |

|Copy of Power of Attorney or Particulars of Directors and Secretaries (if applicable – see section 12) | |

|All Officers on board the named vessel must submit their Cook Islands Crew Endorsement Application Form 16 to Maritime | |

|Cook Islands for processing | |

|Documents to be attached in this Application |

|for the processing of ship’s PERMANENT Registration |

|Original Application Form (duly executed and witnessed as specified in Part 12) | |

|Copy of certificate of incorporation of a new Cook Islands international company OR certificate of registration of an | |

|existing Foreign Company on the Cook Islands Companies Register | |

|Original or duly validated* copy of Bill of Sale OR Builder’s Certificate (new construction only) | |

|Original or duly validated* copy of Deletion Certificate (from ship’s previous Registry) | |

| Copy of Class Certificates issued under Cook Islands Registration | |

| Copy of certificate from ship’s P&I insurance company (including crew insurance) | |

|Copy of confirmation (letter or email) from Radio Accounting Authority that they will agree to act as AA while vessel | |

|under Cook Islands Flag | |

|Original or duly validated*copy of interested shareholders (if applicable) | |

|Original or duly validated*copy of Power of Attorney or Particulars of Directors and Secretaries (if applicable) | |

|Original or duly validated* copy of deletion CSR from previous flag | |

|Original or duly validated* copy of new LRIT Conformance Test Report from Recognised ASP | |

|All Officers on board the named vessel must have received either | |

|a Letter of Acknowledgement for submitting their Crew Endorsement Application Form 16 or | |

|a Cook Islands Crew Endorsement Certificate. | |

* Reviewed, signed and sealed by a Justice of the Peace, a Commissioner for Oaths, Solicitor, Notary Public or the Registrar or Deputy Registrar of Ships of the Cook Islands Ships Registry or before any person authorised by law to administer oaths in the country where the declaration is made.

N.B. The Registrar has the discretion to require, if deemed necessary, additional surveys to be conducted before issuance of a Permanent Certificate of Registry.

|THIS SECTION IS FOR REGISTRY OFFICE USE ONLY |Received: | |

|NAME UNDER COOKS REGISTRY |OFFICIAL No. | CALL SIGN |MMSI No. |

| | | | |

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