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MMSI ASSIGNMENT FORM
* Denotes a required field. These fields must be completed in order to receive an MMSI#.
*OWNER'S FIRST NAME:
* OWNER'S LAST NAME:
OR COMPANY NAME:
* STREET ADDRESS:
* CITY:
* ZIP CODE:
*OWNER'S HOME PHONE:
OWNER'S WORK PHONE:
*PRIMARY EMERGENCY CONTACT ASHORE:
*PRIMARY CONTACT HOME PHONE:
PRIMARY CONTACT WORK PHONE:
ALTERNATE CONTACT ASHORE:
ALTERNATE CONTACT HOME PHONE:
ALTERNATE CONTACT WORK PHONE:
VESSEL NAME:
VESSEL WIRELESS PHONE 1:
VESSEL WIRELESS PHONE 3:
VESSEL FLAG STATE:
*SHIP CLASSIFICATION (SEE TABLE BELOW):
EX-SHIP NAME (IF KNOWN):
EX-CALL SIGN (IF KNOWN):
*VESSEL REGISTRATION/DOCUMENTATION NUMBER:
*VESSEL HOME PORT:
PORT CITY:
ALTERNATE VESSEL HOME PORT:
*CAPACITY (# OF PERSONS EXPECTED TO BE ON BOARD):
SHIP'S RADIO INSTALLATION (VHF, DSC, MF/HF WITH DSC, MF/HF W/O DSC,
AIS TRANSPONDER, CELLULAR PHONE #, ETC.):
REMARKS (BOAT LENGTH, COLOR, TYPE, ETC.):
*The SHIP CLASSIFICATION TABLE may be found on the next page (scroll down to view on the web browser).
* STATE:
PROVINCE, MAIL CODE, COUNTRY:
EMAIL ADDRESS:
RADIO CALL SIGN:
WIRELESS 2:
WIRELESS 4:
EPIRB ID CODE:
PORT STATE:
Y1-03-0183-1 Rev. A
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