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UNITED STATES OF AMERICA FEDERAL MARITIME COMMISSION Washington, DC 20573 www.fmc.gov Application for Certificate of Financial Responsibility |
Form FMC-131 (Rev. xx/2011)
OMB No. xxxx-xxxx Expires x/xx/201x
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Submit
original application and Vessel Schedule for each vessel to: Federal
Maritime Commission ● Bureau of Certification and Licensing ●
800 North Capitol St. NW, Washington, DC 20573
Fax (202)
523-5830
T ype of Certificate: Performance Casualty Both
1. (a) Applicant’s legal business name and trade name(s) used (provide English translation if other than English):
__________________________________________________________________________________________
__________________________________________________________________________________________
(b) Street Address: ______________________________________________________________________
__________________________________________________________________________________________
(c) Phone: ______________________ (d) Fax: ___________________ (e) email: ____________________
(f) U. S. Taxpayer Identification Number (TIN), if applicable: ____________________________________
2. (a) Applicant’s legal form of organization, i.e., corporation, partnership, limited liability company, or other form of business association:
__________________________________________________________________________________________
(b) If a corporation, Limited Liability Company, or Partnership, provide state or country in which incorporated or formed and date of incorporation or formation:
__________________________________________________________________________________________
__________________________________________________________________________________________
3. Name and address of applicant’s U.S. agent or other person authorized to accept legal service in the United States (submit statement of acknowledgement from agent or other authorized person):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Phone: __________________________ Fax: _______________________ email: ________________________
4. Number of vessels included in application: _____ Complete and attach a Vessel Schedule for each vessel.
Use as many Vessel Schedule sheets as necessary.
5. Intended evidence of financial responsibility (check all that apply):
Insurance
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Guaranty
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Escrow |
Surety Bond
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Self Insurance (Casualty Only)
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Other (explain below)
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_________________________________________________________________________________________
_________________________________________________________________________________________
Declaration: I declare under penalty of perjury under the laws of the United States of America that the information provided herein is true, correct, and complete.
By: _____________________________________Date: ____________________________________________
(Signature of official)
________________________________________Address: __________________________________________
(Printed Name)
________________________________________ __________________________________________
(Title)
__________________________________________
If not a corporate officer or partner, please submit a Power of Attorney to demonstrate your authority to submit this application.
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Form FMC-131 - continued Application for Certificate of Financial Responsibility
Vessel Schedule
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N ew Schedule
Amended Schedule
Check One |
Submit a Vessel Schedule for each vessel to: Federal Maritime Commission ● Bureau of Certification and Licensing
● 800
North Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830
VESSEL SCHEDULE FOR __________________________________________________________________
(Name of Vessel)
Applicant: _________________________________________________________________________________
Please submit the following documents with this schedule:
1. Copy of the Certificate of Vessel Registry if not U.S. flagged or Copy of the Certificate of Documentation if U.S. flagged |
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2. Copy of U.S. cruise itinerary |
3. Specimen copy of passenger ticket/passage contract |
4. Copy of payment and cancellation policy |
5. Copy of charter agreement (if any) |
Previous vessel name if any: __________________________________________________________________
Number of passenger berths: _________ Total shipboard berths: _________
Please attach information showing fare structure, i.e., number of passenger berths in each price category.
Principal Codes – On the next page, provide information on all principals, indicating which of the following describes each principal. Use the letter code(s) below to identify all that apply to each principal.
A. Owner
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B. Operator
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C. Parent Company
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D. Ticket/Contract Issuer
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E. Marketing Agent
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F. Charterer
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G. Technical Manager
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H. Other (describe)
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Principal Information
Legal Name of Principal and Trade Name(s) used (provide English translation if not in English):
_________________________________________________________________________
_________________________________________________________________________
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Principal Code:
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Street Address: ____________________________________________________________________________
__________________________________________________________________________________________
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Phone: __________________________ Fax: _______________________ email: ________________________ |
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U.S. Agent for service of process and street address (if other than agent designated by applicant in item 3 of the Form FMC-131 application):
__________________________________________________________________________________________
__________________________________________________________________________________________
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Phone: __________________________ Fax: _______________________ email: ________________________
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By: _____________________________________Date: ___________________________________________
(Signature)
________________________________________Telephone: ________________________________________
(Printed Name)
________________________________________
(Title)
Submit
this vessel schedule for each vessel to: Federal Maritime Commission
● Bureau of Certification and Licensing ● 800 North
Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830
Attach continuation sheet(s) to add additional principal
Legal Name of Principal and Trade Name(s) used (provide English translation if not in English):
_________________________________________________________________________
_________________________________________________________________________
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Principal Code:
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Street Address: ____________________________________________________________________________
__________________________________________________________________________________________
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Phone: __________________________ Fax: _______________________ email: ________________________
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U.S. Agent for service of process and street address (if other than agent designated by applicant in item 3 of the Form FMC-131 application):
__________________________________________________________________________________________
__________________________________________________________________________________________
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Phone: __________________________ Fax: _______________________ email: ________________________
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Form FMC-131 - continued
Vessel Schedule
Continuation Sheet for _______________________________ (Name of Vessel) |
Sheet
____ of ____ |
Submit
this vessel schedule for each vessel to: Federal Maritime Commission
● Bureau of Certification and Licensing ● 800 North
Capitol St. NW, Washington, DC 20573
Fax (202) 523-5830
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Appendix G - FMC-131 ShortForm - Revised 20Dec2010.docx |
Subject | Appendix G - FMC-131 ShortForm - Revised 20Dec2010.docx |
Author | J Nussbaumer |
File Modified | 0000-00-00 |
File Created | 2021-01-31 |