Application for Renewal of a Pilotage Exemption Certificate

/ CC 14
January 2016

Application for renewal of a Pilotage Exemption Certificate

Marine Safety Act 2010(Vic), Marine Safety Regulations 2012(Vic), Marine Standard No. 6.3 Training and Certification of Pilot Exempt Masters for Victorian Ports

Things to know before applying

An application for renewal of a pilotage exemption certificate must be made before it expires. You are not able to act as a Pilot Exempt Master once your pilotage exemption certificate has expired.

Fees and payment

You must pay the applicable fees for the renewal of your pilotage exemption certificate when lodging your application with Maritime Safety Victoria (MSV). The applicable fees can be paid by cheque, money order or by Bpay using the reference details on your Request for Payment. A pilotage exemption certificate cannot be issued until all fees have been paid. For information about the fees for pilotage exemption certificates, please contact MSV.

Pilotage exemption certificates are valid for two (2) years unless cancelled.

Attachments

As part of the renewal application you must attach the following mandatory supporting documentation:

a certified copy of yourcurrent and valid unlimited certificate of competency as a Master Class 1 issued by the Australian Maritime Safety Authority (AMSA) or a current and valid certificate of competency otherwise accepted by the Safety Director.

a certified copy of your current and valid certificate of medical fitness (which includes eyesight requirements), issued by an AMSA approved medical inspector, certifying you are medically fit to perform the duties of a pilot exempt master.

a letter from the relevant port office/s confirming your visit to receive a refresherin the operational procedures of that port.

evidence of your ongoing service as a Pilot Exempt Master within the two (2) year validity period of your certificate.
(The minimum requirement that apilotage exemption certificate must be used by a pilot exempt master is at least once every six (6) months)

evidence of assessment by a Check Pilot that you have successfully completed one (1) check trip within each 12-month period of the two (2) year validity of your certificate. (These check trips should be undertaken within a 6-week period of the yearly anniversary)

two (2)identical passport size photos (approximately H45mm x W35mm) with your signature on the back. Photos must be less than 12 months old, showing a full front view of your head and shoulders without any head covering or tinted glasses. If you wear a head covering for religious reasons, a photograph showing your facial features is acceptable. If you normally wear prescription glasses, you must be wearing glasses with untinted lenses. The photograph must have a plain and lightly coloured background.

How to lodge

Send your completed application and attachments by post to Maritime Safety Victoria, PO Box 2797 Melbourne VIC 3001.

What happens next?

If the form is completed correctly and all necessary documents are attached, please allow four (4) weeks for processing.
If requested by MSV, you may be required to provide further information or material in respect of the application.
You may also be required to have the information or material verified.
If any change occurs in the information you have provided in your application, you must notify MSV as soon as possible.

Please contact MSV on 1800 223 022 should you have any questions regarding this application.

Privacy

Maritime Safety Victoria, a branch of Transport Safety Victoria (TSV) collects and holds the personal information provided in this application to assist the Director, Transport Safety (Safety Director) to administer the Marine Safety Act 2010 (Vic) and Marine Safety Regulations 2012 (Vic). TSV is committed to protecting personal information in accordance with its obligations under the Marine Safety Act 2010 (Vic). The personal information provided in this application may be disclosed to other government agencies in accordance with section 306 of the Marine Safety Act 2010 (Vic) and section 177 of the Transport Integration Act 2010 (Vic). It is an offence under the Marine Safety Act 2010 (Vic) to give information that is false or misleading in order to obtain or attempt to obtain a certificate. The individuals whose personal information is collected on this application have a right to seek access to this personal information and to seek correction of any error in the personal information held. All individuals whose personal information is included with this application should be informed of this fact. For more information on privacy please refer to TSV's privacy statement at

CC 14
January 2016

Application for renewal of a Pilotage Exemption Certificate

Marine Safety Act 2010(Vic), Marine Safety Regulations 2012(Vic), Marine Standard No. 6.3 Training and Certification of Pilot Exempt Masters for Victorian Ports

Your details (the applicant)

Provide details of the certificate of competency you hold as a Master

Level of certificate (e.g Master 1)Certificate numberIssuing authority

AMSA Other (specify)

Your surnameGiven names

Date of birth (dd/mm/yyyy)City or town of birthStateCountry Australiaor specify

GenderHeight (centimetres)Eye colour

Male Female / Blue Brown Green Grey Hazel

Hair colour

Black Blonde Brown Grey Red Bald Other (specify):

Residential address

Street number and name

SuburbStatePostcode

Postal address

Same as residential address

OR Street number and name/PO Box

SuburbStatePostcode

Mobile numberDaytime telephone number

Same as mobile OR ()

EmailFax number (if applicable)

()

Your employer details

Provide details of your employer

Business nameABN

Postal address

Street number and name/PO Box

SuburbStatePostcode

Telephone numberFax number

() / ()

Details of certificate required

Ports and berths

For whichport/s and berth/s is the pilot exemption certificate being renewed?

Port/s / Berth/s
Port of Geelong
Port of Hastings
Port of Melbourne
Port of Portland
Other port (specify)

Vessels

For which vessel/s is the pilot exemption certificate being renewed?

Vessel name / Call sign / Where registered / Gross tonnage / Total length
(metres) / Summer draught

Applicant’s photograph

Provide two(2) identical passport size photographs of yourself that are less than 12 months old with your signature on the back.
Attach one below and include a second with this application.

Declaration and signature

Applicant declaration and signature

I declare that:

I hold a current and valid unlimited certificate of competency as a Master Class 1 issued by the Australian Maritime Safety Authority (AMSA) or a current and valid certificate of competency otherwise accepted by the Safety Director
I hold a current and valid certificate of medical fitness, including eyesight requirements
I have visited the relevant port office/s and received a refresherin the operational procedures of that port
I have been engaged in ongoing service as a pilot exempt master within the last two (2) year validity period of my certificate
I have undertaken and completed the required check trips with a Check Pilot

the supplied photographs are a true representation of me as the applicant
all particulars supplied on this application form and any attachments are true and correct.

I understand it is an offence under section 305 of the Marine Safety Act 2010(Vic)to provide any false or misleading information and that penalties apply.

Signature of applicant Date

Privacy

This page is left intentionally blank

CC 14 – 01/2016 / Page 1 of 10

Pilotage Exemption Certificate – Evidence of ongoing trips (for continuing service)Applicant’s name ______

Date / Name of vessel / Length overall / Draught / Port / In / Out / Time of passing entrance / Time berthed / unberthed / Via channel navigated / Day / Night / Rank / Signature of observer
CC 14 – 01/2016 / Page 1 of 10