/ The Republic of
the Marshall Islands
Maritime Administrator / THIS SPACE FOR OFFICIAL USE ONLY
OFFICIAL NO.
CALL SIGN

APPLICATION FOR OFFICIAL NUMBER, CALL SIGN AND REGISTRATION OF VESSEL

PART 1. GENERAL

FOR COMMERCIAL YACHTS ONLY – DESIRED PORT OF REGISTRY: (SELECT ONE) JALUIT BIKINI

NEW NAME / PRESENT NAME / IMO NUMBER
PRESENT COUNTRY OF REGISTRY / SHIP TYPE / CLASSIFICATION SOCIETY
NAME OF OWNER(S) / IMO OWNER NUMBER / EXPECTED DATE OF REGISTRATION
DOMICILE / ADDRESS (for FMEs, full address) / CITIZENSHIP / PERCENTAGE

PART 2. GENERAL PARTICULARS

BUILT BY / HULL NO. / YEAR BUILT / PLACE BUILT
NUMBER OF MASTS / NUMBER OF DECKS / HULL MATERIAL / DATE AND PLACE OF CONVERSION
PROPELLING POWER / NUMBER AND TYPE OF ENGINES / NAME OF ENGINE MANUFACTURER / AUTOMATED EN/RM
LENGTH / BREADTH / DEPTH / AIR DRAFT (HEIGHT) / HULL TYPE
GROSS TONS / NET TONS / DEADWEIGHT TONS / KEEL LAYING DATE / DELIVERY DATE

PART 3. DECISION-MAKER (please complete MI-297B for Declaration of Designated Person, where applicable)

Pursuant to Marshall Islands Maritime Regulations 1.07.2

NAME: / ADDRESS:
COMPANY:
TELEPHONE: / MOBILE:
FAX:
EMAIL:

PART 4. BILLING

(includes correspondence, miscellaneous, etc.)

Billing should be sent to the following:

COMPANY: / ADDRESS:
ATTN:
TELEPHONE: / FAX:
EMAIL:

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PART 5. TONNAGE TAX Check if Tonnage Tax information is same as Billing information

(only for invoices with respect to tonnage taxes and annual fees)

Tonnage Tax invoices should be sent to the following:

COMPANY: / ADDRESS:
ATTN:
TELEPHONE: / FAX:
EMAIL:

PART 6. MORTGAGE RECORDATION

Do you intend to record a mortgage?Yes No

PART 7. RADIO COMMUNICATIONS

A contract has been (or will be) entered into with
radio company, which will be responsible for all communications accounts and for the obtaining of a Marshall Islands Ship Radio Station License. Pending the effective date of such contract and the issuance of said license, responsibility for payment of accounts and correspondence relative to the radiotelegraphy/telephony service of the vessel is hereby assumed by applicant owner(s).

PART 8. OATH OF OFFICER OF AN INCORPORATED COMPANY AND AFFIRMATION RE SURRENDER OF FOREIGN DOCUMENTS AND MAKING OF MARKINGS

I, / a citizen of / residing
at (SEE NOTE 1) / , swear or affirm, as
required by Section 209 (1) of the Marshall Islands Maritime Act, that I am the (SEE NOTE 2)
authorized in writing of
a corporation organized and existing under the laws of
with offices at (SEE NOTE 1)
that said corporation is or will be owner of the vessel called
Official Number / , net tonnage / , built in
at / ; that the names and residences of the owner(s)
or prospective owner(s) and his/her (their) respective citizenship(s) and proportion(s) of ownership in the vessel is(are) as follows:
Name / Residence / Citizenship / Proportion
and that / , the present or prospective Master of said
vessel, is a citizen of / , and further, that the Master has been ordered
and instructed, upon receipt of the vessel's Marshall Islands Certificate of Registry and other Documents, to surrender
the vessel's outstanding documents issued by the Government of
and to make the Markings required by Section 230 of the Marshall Islands Maritime Act, as amended.

Notes:

1.Enter street address, city and country.
2.Enter President, Vice-President, Secretary, Assistant Secretary, Agent, Attorney-in-Fact, whichever title applies.
(SIGNATURE)
Subscribed and Sworn Before me
this / day of / 20
at / (TITLE)
SIGNATURE OF NOTARY PUBLIC, OR OTHER OFFICER AUTHORIZED
BY MARSHALL ISLANDS LAW TO ADMINISTER OATHS

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ANNEX 1

Rev. 5/101MI-100

ANNEX 1

Rev. 5/101MI-100