Northern Territory Consolidated Regulations

MARINE (HIRE-AND-DRIVE VESSEL) REGULATIONS - SCHEDULE

Schedule

regulation 5

NORTHERN TERRITORY OF AUSTRALIA

Marine Act

MARINE (HIRE-AND-DRIVE VESSEL) REGULATIONS

APPLICATION FOR GRANT OR EXTENSION OF PERMIT

NOTE:     A SEPARATE APPLICATION IS REQUIRED FOR EACH TYPE AND LENGTH OF VESSEL

Full Name of Applicant:

Residential Address:

Postal Address:

Date of Birth:             Telephone:     (BH) (AH)
Description of Vessel:
    Type:
    Make:                     Year Built:
    Length(m):                 Colour:
    Engine Details:
        Make:                 Model No:

        Kws:

Proposed Area of Operation: (Please include a drawing, map or chart detailing proposed area)

Hours of Operation:

Description of Emergency Support System:

Signature of Applicant:

Date:

NOTE:     The statutory declaration on the reverse of this form is to be completed prior to submitting the application.

The application fee is to be submitted at the time of making the application.

Vessels may not be hired until they have been inspected and the permit is issued.

Detailed descriptions of the vessels, the subject of this application, may be attached to, and form part of, this application.

(Reverse of Form)

STATUTORY DECLARATION

I, , the applicant whose details are entered on the application on the front of this form do solemnly and sincerely declare:

.     I am the legal owner of the vessel(s) the subject of the application for a permit to operate a hire-and-drive vessel.

.     I am fully authorised to assume the responsibilities of a permit holder by the legal owner(s) of the vessel(s) the subject of this application for a permit to operate a hire-and-drive vessel.

(cross out whichever is not applicable)

.     I fully understand the obligation and liabilities of a permit holder and accept the responsibilities of a permit holder in accordance with the Marine (Hire-and-Drive Vessel) Regulations .

This declaration is true and I know it is an offence to make a statutory declaration knowing it is false in a material particular.
Declared by
[Signature of person making declaration]    

at [place]     on [date]    
Witnessed by

[Signature of witness]    

[Name]    

[Address or telephone number]    

NOTE:     This declaration may be witnessed by any person who is at least 18 years of age.

NOTE:     Making a declaration knowing it is false in a material particular is an offence for which you may be fined or imprisoned.