License Application Form

SCHEDULE 1
TREATY ON FISHERIES BETWEEN THE
GOVERNMENTS OF CERTAIN PACIFIC ISLAND
STATES AND THE GOVERNMENT OF THE
UNITED STATES OF AMERICA
LICENCE APPLICATION FORM
Application is hereby made for a license authorizing the use of the vessel named in this application for fishing in
the Licensing Area.
1.

FULL NAME OF VESSEL:________________________________________________________________

2.

RADIO CALL SIGN OF VESSEL:__________________________________________________________

3.

REGIONAL REGISTER NUMBER OF VESSEL:______________________________________________
(If none, fill in and attach the FFA Regional Register form)

4.

FULL NAME AND ADDRESS OF EACH PERSON WHO IS AN OPERATOR OF THE VESSEL AND
STATE WHETHER OWNER, CHARTERER, MASTER OR OTHER. IF OTHER, SPECIFY DETAILS:
______________________________________________________________________________________
______________________________________________________________________________________

5.

FULL NAME AND ADDRESS OF INSURER FOR PURPOSES OF ARTICLE 4.3(a) OF THE TREATY:
______________________________________________________________________________________
______________________________________________________________________________________

6.

REGISTRATION NUMBER AND MAKE OF HELICOPTER, IF ANY, TO BE CARRIED ON VESSEL:
______________________________________________________________________________________

7.

REGISTRATION NUMBER, MAKE AND NAME AND ADDRESS OF OPERATOR OF ANY
AIRCRAFT TO BE USED IN ASSOCIATION WITH FISHING ACTIVITIES:
______________________________________________________________________________________
______________________________________________________________________________________

8.

STATE WHETHER OWNER OR CHARTERER IS INSOLVENT OR IN ANY BANKRUPTCY
PROCEEDING UNDER THE BANKRUPTCY LAW OF THE UNITED STATES:
______________________________________________________________________________________

9.

STATE WHETHER OPERATOR OF VESSEL HAS BEEN INVOLVED IN A VIOLATION OF THE
TREATY. IF YES, SPECIFY DETAILS:
______________________________________________________________________________________

________________________
Date of Application

______________________________________
Administrator of the Pacific Islands Region
National Marine Fisheries Service
National Oceanic and Atmospheric
Administration

OMB Control No.: 0648-0218
Expiration Date: 10/31/2007