Restricted Use Flag Application

Transport Operations (Marine Safety) Act 1994 If the flag is to be registered in a registered Business/Company name answer questions in Section A.

Otherwise

If the flag is to be registered in a private name answer questions in Section B.

(please print in full) Registered Business/Company name Family name

Section A.

(please print in full)

Section B.

ACN, ABN or Dealer's Licence No

Given name/s

Male Female

Address of premises where flag is to be kept

Joint holder's family name

Postcode
Postal address

Given name/s Residential address

Male Female

Is the Business/Company registered with the Australian Securities Commission? Please produce certificate or company cheque which Yes shows the ACN (Australian Company Number) or BN (Business Number) with this application. No Name of nominee of business or responsible person

Postcode
Postal address

Intended registered holder's Queensland driver licence No.

The person lodging this application will need to provide evidence of identity. (see overleaf for requirements)

Joint holder's Queensland driver's licence No.

A letter of authority is required if this application is being lodged on behalf of the intended registered holder/s. The person lodging this application will need to provide evidence of identity. (see overleaf for requirements) What is the specific purpose the Restricted Use Flag will be used for? (Include nature of activity, locality, ship description, voyages being undertaken etc.)

How many flags do you require? How long will you require the flag/s? Up to one month More than one month

Signature/s of Applicant/s
I/We declare that 1. The information provided is true and correct. 2. The Restricted Use Flag will only be used in accordance with any authority issued in connection with this application

Signed (all signatures are required if the flag is to be registered in more than one name)

Date
day

/ month /

year

The details provided have been verified. Signed Date

/ /

Office use only Receiving Officer's Verification

Receipt No Flag number/s

Date ___ /___ /____

Issue date ____ /____ /____ Expiry date ___ /___ /____
D&FM Form F1572 ES Aug 2004

Evidence of identity requirements

You must give evidence of your identity at the time of making this application. If you do not have a Queensland driver licence (current or expired less than 2 years), you must show at least three (3) evidence of identity documents. These documents must include at least one Category A and at least one Category B document. The third document may be from either category, however, one of these documents must include your signature. If you have changed your name or the details of your name are different on the documents provided, you must provide evidence of the name change from the relevant Registrar of Births, Deaths and Marriages. Each document must be an original document.

Evidence of identity documents include:

Category A Australian Birth Certificate (full) Australian Passport (current or expired less than 2 years) Foreign Passport (current or expired less than 2 years) Queensland Card 18+ (issued after 01/01/92) Australian Citizenship or Naturalisation Certificate Australian photo driver licence (current or expired less than 2 years) Category B Medicare card Financial institution debit/credit card (must include signature and embossed name) Education institution student identity document (must include photo and signature) Dept of Veterans Affairs/Centrelink Pensioner Concession card

Privacy Disclaimer The information you provide to Maritime Safety Queensland on this form is collected for the purpose of providing a register of registered ships within Queensland. Personal information such as the owner's name and address will be available to the public as a public register on the Commercial Information and Registration Management System (CIRMS) in accordance with the Transport Operations (Marine Safety) Act 1994.

List of Maritime Safety Queensland Regional Offices Centre

Pinkenba

Office Address
Macarthur Avenue East, Pinkenba QLD 4008

Postal Address
Macarthur Avenue East, Pinkenba QLD 4008 PO Box 107, Southport QLD 4215 PO Box 1094, Mooloolaba, QLD 4557 PO Box 476, Bundaberg QLD 4670 Buccaneer Avenue, Urangan QLD 4655 PO Box 123, Gladstone QLD 4680 PO Box 10085, Mt Pleasant QLD 4740 PO Box 717, Airlie Beach, QLD 4802 PO Box 1921, Townsville QLD 4810 PO Box 1787, Cairns QLD 4870

Telephone Facsimile (07) (07)

3860 3561 5583 8300 5477 8425 4131 5608 4128 9555 4973 1200 4944 3700 4946 2200 4771 5135 4052 7400 3860 3540 5583 8288 5444 6697 4152 8528 4128 9007 4972 5520 4944 3790 4946 2233 4721 2028 4035 1127

Gold Coast 40-44 Seaworld Drive, Main Beach, QLD 4215 Mooloolaba Old Pilot Station, Parkyn Parade, Mooloolaba QLD 4557 Bundaberg Level 2, 46 Quay Street Bundaberg QLD 4670 Urangan Gladstone Mackay Buccaneer Avenue, Urangan QLD 4655 Level 2, 136 Goondoon Street, Gladstone QLD 4680 14 Discovery Lane, Mt Pleasant QLD 4740

Airlie Beach Level 1, 384 Shute Harbour Road, Airlie Beach QLD 4802 Townsville Cairns 60 Ross Street, South Townsville QLD 4810 64-66 Tingira Street, Portsmith QLD 4870