![](media/image1.png){width="2.7104166666666667in"
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POLICY GUIDELINES FOR FOREIGN FISHING BOATS

SEEKING ACCESS TO AUSTRALIAN PORTS

UNDER SECTION 94 OF THE

*FISHERIES MANAGEMENT ACT 1991*

For foreign boats not holding a foreign fishing boat licence

![](media/image2.png)

Australian Fisheries Management Authority

As at September 2001

![](media/image1.png){width="2.7104166666666667in"
height="0.8222222222222222in"}

![](media/image3.png)

Australian Fisheries Management Authority

Contents

**INTRODUCTION [1](#introduction)**

> Port Access [1](#port-access)

CONSIDERATION OF PORT PERMIT APPLICATIONS
[1](#consideration-of-port-permit-applications)

> Applying for a Port Permit [2](#applying-for-a-port-permit)
>
> Type of Approval [2](#type-of-approval)
>
> Vessel Monitoring Systems (VMS) [2](#vessel-monitoring-systems-vms)

PORTS [3](#ports)

CONDITIONS SPECIFIED IN THE PERMIT
[3](#conditions-specified-in-the-permit)

FEES [4](#fees)

Port Access in Circumstances of Emergency
[4](#port-access-in-circumstances-of-emergency)

CONTACT DETAILS [4](#contact-details)

ATTACHMENT A - Application for a Port Permit [5](#attachment-a)

ATTACHMENT B - DNID Download Agreement Form [8](#attachment-b)

ATTACHMENT C - Inmarsat Distress Alert Contact Details Form
[10](#attachment-c)

# INTRODUCTION

The following guidelines have been prepared to provide advice on the
procedures relating to the approval of port access to foreign fishing
boats under section 94 of the *Fisheries Management Act 1991* (the Act).

The Australian Fisheries Management Authority (AFMA) is responsible for
the management of fisheries on behalf of the Commonwealth of Australia.
The Department of Agriculture, Fisheries and Forestry - Australia has
broad responsibilities for policy and administration of Commonwealth
fisheries, especially for international fisheries issues.

# Port Access

Under section 94 of the Act, AFMA may issue a port permit, which
authorises a foreign fishing boat, which is not subject to a foreign
fishing boat licence, to enter an Australian port.

For the purposes of section 94 of the Act, a foreign fishing boat is:

-   a foreign boat that is equipped for fishing; or

-   a foreign boat that AFMA has reasonable grounds to believe is being
    used or is intended to be used, in activities in support of fishing
    by foreign boats.

A port permit is subject to the conditions specified in the permit and
comes into force on the day specified or from the day of granting and
remains in force until the day specified. The landing of fish and fish
products requires separate approval by the Minister responsible for
fisheries under the Customs (Prohibited Imports) Regulations 1956.

# CONSIDERATION OF PORT PERMIT APPLICATIONS

AFMA takes into account a number of matters, including the following, in
assessing applications for port permits:

(i) the requirement for Australia to meet its obligations under
    international law and, in particular, to give effect to
    international agreements and arrangements concerning fishing
    activities and the conservation and management of fish stocks and
    other living marine resources; and

(ii) that the boat and/or master and/or fishing company can be expected
     to abide by the terms and conditions of a port permit, based on an
     assessment of their previous behaviour.

Applicants should note that applications for port permits are considered
on a case-by-case basis and that AFMA may decline to grant a port
permit, vary the conditions on a permit or revoke a permit in certain
circumstances. The reasons for declining the application will be
conveyed to the applicant.

Applicants should note that foreign fishing boats are subject to
Australian law whilst in Australian jurisdiction.

# Applying for a Port Permit

Applications for a port permit should be made to AFMA by the company
operating the foreign fishing boat, the master of the foreign fishing
boat or an Australian-based agent appointed by the owner of the foreign
fishing boat. All applications must be made in writing using the AFMA
application form (**Attachment A**).

All applications for port permits must contain the following information
required by AFMA and other Australian authorities (including the
Australian Quarantine and Inspection Service and Australian Customs
Service):

(i) proposed port of entry;

(ii) boat name and nationality;

(iii) International Radio Call Sign;

(iv) registration number in country of origin and International Maritime
     Organisation (IMO) number;

(v) description of authorisations to fish;

(vi) the name of the master of the boat;

(vii) the person or contact point of the company or individual that owns
      the boat and will be responsible for the conduct of the boat as
      the approval holder; and

(viii) crew list.

AFMA may request further information be provided by the applicant where
necessary.

Please note that as part of the assessment process, any information
provided in the form submitted by an applicant may be made available to
relevant Australian government agencies as part of the internal
assessment process.

Applicants must allow for at least three (3) working days for the
application to be processed (applicants will be informed as soon as
possible should the application take longer).

# Type of Approval

In accordance with section 94 of the Act, a port permit granted by AFMA
may authorise a foreign fishing boat to enter a specified Australian
port on:

(i) one occasion; or

(ii) such number of occasions as are specified in the permit.

# Vessel Monitoring Systems (VMS)

AFMA requires a foreign fishing boat granted a port permit to carry and
operate an AFMA type-approved VMS (Inmarsat C) that enables AFMA to at
all times independently monitor the movement and location of the boat
whilst it is in Australian jurisdiction. The following are AFMA
type-approved units:

-   Thrane and Thrane Capsat transceiver model TT3022D, using software
    version 3.11

-   Thrane and Thrane Capsat transceiver model TT3022D, using software
    version 3.24

-   Trimble Galaxy transceiver model TNL 7001, using software version
    5.10a

-   Trimble Galaxy transceiver model 8001 (Courier), using software
    version 5.10

-   Trimble Galaxy transceiver model TNL 7005 (non solas), using
    software version 5.10

-   Trimble Galaxy transceiver model TNL 8001 (Sentinel), using software
    version 5.10

-   Furuno Inmarsat C transceiver model Felcom 12 (IC-212), using
    software DCE version .07+FFA

-   Japan Radio Company Limited Inmarsat C transceiver model JUE-75CV,
    using software version 6.1

-   Japan Radio Company Limited Inmarsat C transceiver model JUE-75C,
    using software version 8.0.

Prior to a Port Permit being issued the Applicant will need to provide
to AFMA a completed and signed Data Network Identifier (DNID) Download
Agreement Form (copy at **Attachment B**) and on a voluntary basis, an
Inmarsat Distress Alert Contact Details Form (copy at **Attachment C**).

In exceptional circumstances, AFMA may consider applications for *ad
hoc* and transitional communication arrangements.

# PORTS

Applicants may apply for access to all major Australian ports.
Australia's major ports are Albany, Brisbane, Cairns, Darwin, Fremantle,
Hobart, Port Hedland and Sydney. Applicants should contact AFMA before
submitting an application if access is sought to any other port.

# CONDITIONS SPECIFIED IN THE PERMIT

Standard terms and conditions will be applied to a port access permit,
granted under section 94 of the Act, as outlined below (a port permit
may be subject to such other conditions as are specified by AFMA):

(i) the boat's nets, traps or other equipment used for searching for or
    taking fish are to be stowed and secured while the boat is in the
    Australian Fishing Zone (AFZ) and in port;

(ii) the boat must transit to and from port by the most direct route
     towards its proposed destination;

(iii) the master or agent must provide AFMA at least 24 hours notice of
      intention to enter the AFZ and depart port;

(iv) the master of the boat shall maintain the operation of the
     'Inmarsat C' Vessel Monitoring System (VMS), reporting to AFMA at
     all times whilst in the AFZ, unless transitional or other *ad hoc*
     communication arrangements have been approved by AFMA;

(v) the boat's freezer plans are to be made available to the inspecting
    Fisheries Officer on request;

(vi) a copy of the boat's declaration of catch in total weight, and
     weight and number by species must be provided to AFMA (via e-mail
     portpermit@afma.gov.au or by facsimile +61 2 6272 5784) on entry to
     the AFZ. This information is also to be made available to the
     inspecting Fisheries Officer upon request;

(vii) all fish and fish products are to be stowed and secured inboard
      the boat; and

(viii) no fish or fish product is to be unloaded for any purpose,
       including sale, own consumption, donation or gift, unless
       separate permission is obtained.

# FEES

The fees associated with port permit approvals are based on full cost
recovery for the services provided.

A fee of A\$750.00 will be charged by AFMA for each successful
application to visit an Australian port. The fee is charged for each
visit that is requested in the application. The fee is payable upon
application, and can be made by cheque or bank transfer of money to
AFMA's designated bank account.

In the event that an application is denied, A\$336.00 per visit will be
refunded to the applicant, with the remainder being retained to cover
administrative costs associated with processing the application.

Cheques can be made payable to the

> **Australian Fisheries Management Authority**.

Details for telegraphic transfer are:

> **AFMA Levies and other Collections**
>
> **National Australia Bank**
>
> **BSB Number: 082-914**
>
> **Account Number: 626 480 173**

# Port Access in Circumstances of Emergency

Australia attaches the highest importance to the safety of life and
vessels at sea and in accordance with Australia's international
obligations foreign fishing boats may enter an Australian port without
need of a port permit in genuine cases of emergency.

# CONTACT DETAILS

Please direct any enquiries relating to these guidelines to:

Port Permit Inquiry\
Australian Fisheries Management Authority\
Box 7051\
Canberra Mail Centre ACT 2610\
AUSTRALIA

> Phone: +61 2 6272 5658 or +61 2 6272 5106\
> Facsimile: +61 2 6272 5784\
> E-mail: <portpermit@afma.gov.au>

## ATTACHMENT A

+-----------------------------------+----------------------------------+
| ![](media/image4                  | Return completed form to:        |
| .wmf){width="2.307638888888889in" |                                  |
| height="0.9326388888888889in"}    | Port Permit Application          |
|                                   |                                  |
|                                   | Australian Fisheries Management  |
|                                   | Authority\                       |
|                                   | Box 7051\                        |
|                                   | Canberra Mail Centre ACT 2610\   |
|                                   | AUSTRALIA                        |
|                                   |                                  |
|                                   | Telephone +61 2 62725658 *or*    |
|                                   | +61 2 62725106\                  |
|                                   | Facsimile +61 2 62725784\        |
|                                   | E-mail <portpermit@afma.gov.au>  |
+-----------------------------------+----------------------------------+

  -----------------------------------------------------------------------
  **Application for Port Permit**

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  Application for the issue of a Port permit pursuant to section 94 of
  the [Fisheries Management Act 1991]{.underline}, to

  bring a specified foreign fishing boat\* into an Australian port. There
  should be no presumption made that

  access will be granted. Australia reserves the right as a Coastal State
  to deny port access.
  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  *\*Foreign fishing boat means a foreign boat that is designed and
  equipped for fishing, including boats that are*

  *being, or intended to be used in activities in support of foreign
  fishing.*
  -----------------------------------------------------------------------

  --------------- ----- ------- ------- ------- -- -------------- --- ------- --- ------- -- ---
  1\. **Vessel                                                                               
  details**                                                                                  

                                                                                             

  Vessel name                                      Vessel type                               

                                                   (e.g.                                     
                                                   longliner)                                

                                                                                             

  IMO number                                       Vessel                                    

                                                   registration                              

                                                                                             

  International                                    Vessel flag                               
  radio call sign                                                                            

                                                                                             

                                                                                             

  Description of                                                                             
  vessel (e.g.                                                                               
  size, colour                                                                               
  scheme, GRT,                                                                               
  etc.)                                                                                      

                                                                                             

                                                                                             

                                                                                             

                                                                                             

                                                                                             

                                                                                             
  --------------- ----- ------- ------- ------- -- -------------- --- ------- --- ------- -- ---

  ------------ ----- ------- ------- ------- -- ---------- --- ------- --- ------- -- ---
  2\.                                                                                 
  **Inmarsat                                                                          
  details**                                                                           

                                                                                      

  Inmarsat                                      Inmarsat                              

  Number                                        type                                  

                                                                                      
  ------------ ----- ------- ------- ------- -- ---------- --- ------- --- ------- -- ---

  -------------------------- ----- ------- ------- ------- -- ------- --- ------- ------ ------- -- ---
  3\. **Port details**                                                                              

                                                                                                    

                                                              ETA                 ETD               
                                                              port                port              

  Ports for which                                                                                   

  access is required                                                                                

                                                                                                    

                                                                                                    

                                                                                                    

                                                                                                    

                                                                                                    

  Last port of call                                           Next                                  
                                                              port of                               
                                                              call                                  

                                                                                                    

                                                                                                    

  Note : **Applicants must                                                                          
  allow for at least three                                                                          
  (3) working days for the                                                                          
  application to be                                                                                 
  processed**.                                                                                      

  Transit through the                                                                               
  Australian Fishing Zone                                                                           
  (AFZ) should be made                                                                              
  following notification to                                                                         
  AFMA.                                                                                             

  Fisheries Regulations                                                                             
  provide for notification                                                                          
  of an intention to enter                                                                          
  and exit the AFZ and/or                                                                           
  port. This                                                                                        

  notification may be                                                                               
  provided to AFMA by                                                                               
  facsimile +61 2 62725784,                                                                         
  e-mail to                                                                                         
  <portpermit@afma.gov.au>                                                                          

  or by DNID download.                                                                              

                                                                                                    
  -------------------------- ----- ------- ------- ------- -- ------- --- ------- ------ ------- -- ---

  ---------------- ----- ------- ------- ------- -- ------- --- ------- --- ------- -- ---
  4\. **Fishing                                                                        
  authorisations                                                                       
  held**                                                                               

                                                                                       

  Describe :                                                                           

                                                                                       

                                                                                       

                                                                                       

                                                                                       
  ---------------- ----- ------- ------- ------- -- ------- --- ------- --- ------- -- ---

  ------------- ----- ------- ------- ------- -- ------- --- ------- --- ------- -- ---
  5\.                                                                               
  **Reason(s)                                                                       
  for port                                                                          
  entry**                                                                           

                                                                                    

  Port entry                                                                        
  *may* be                                                                          
  granted for,                                                                      
  but not                                                                           
  limited to;                                                                       
  bunkers,                                                                          
  victuals,                                                                         
  repairs and                                                                       
  maintenance                                                                       
  and/or refit.                                                                     

                                                                                    

                                                                                    

                                                                                    

                                                                                    

                                                                                    

                                                                                    
  ------------- ----- ------- ------- ------- -- ------- --- ------- --- ------- -- ---

  ------------ ----- ------- ------- ------- -- --------- --- ------- --- ------- -- ---
  6\.                                                                                
  **Agent\'s                                                                         
  details**                                                                          

                                                                                     

  Company                                       Fax                                  
                                                number                               

  name                                                                               

                                                                                     

  Contact                                       Mobile                               

  person                                        number                               

                                                                                     

  Telephone                                     E-mail                               

  number                                        address                              

                                                                                     
  ------------ ----- ------- ------- ------- -- --------- --- ------- --- ------- -- ---

  ------------- ----- ------- ------- ------- -- --------- --- ------- --- ------- -- ---
  7\.                                                                                 
  **Master\'s                                                                         
  details**                                                                           

                                                                                      

  Name                                           Address                              

                                                                                      

                                                                                      

  Nationality                                                                         

                                                                                      

                                                                                      

                                                                                      
  ------------- ----- ------- ------- ------- -- --------- --- ------- --- ------- -- ---

  ------------ ----- ------- ------- ------- -- --------- --- ------- --- ------- -- ---
  8\.                                                                                
  **Owner\'s                                                                         
  details**                                                                          

                                                                                     

  Company                                       Address                              

  name                                                                               

                                                                                     

  Contact                                                                            

  person                                                                             

                                                                                     

  Telephone                                                                          

  number                                        Fax                                  

                                                number                               

  Mobile                                                                             
  number                                                                             

                                                E-mail                               

                                                address                              

                                                                                     
  ------------ ----- ------- ------- ------- -- --------- --- ------- --- ------- -- ---

  ---------- ----- ------- ------- ------- ---------------- ------- --- ------- --- ------- -- ---
  9\.                                                                                          
  **Crew**                                                                                     

                                                                                               

  Number of                                Please attach                                       
  people                                   crew list giving                                    
                                           names,                                              
                                           nationalities,                                      
                                           passport numbers                                    

  On board                                 and date of                                         
                                           birth of *each*                                     
                                           crew member                                         

                                                                                               
  ---------- ----- ------- ------- ------- ---------------- ------- --- ------- --- ------- -- ---

<table style="width:100%;">
<colgroup>
<col style="width: 11%" />
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<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4">10. <strong>Signature of Owner/Authorised
agent</strong></td>
<td></td>
<td></td>
<td></td>
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<td></td>
<td></td>
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<td><h3 id="signature">Signature</h3></td>
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</tr>
<tr class="odd">
<td colspan="2">Printed name</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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</tr>
<tr class="even">
<td>Date</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
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<td></td>
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</tr>
</tbody>
</table>

  ---------------------------------- -- ------- --- ------- --- ------- -- ---
  Note : It is an offence under the                                        
  [Fisheries Management Act                                                
  1991]{.underline}, for a person                                          
  (or persons) to make a                                                   

  statement or furnish information                                         
  in an application that is, to the                                        
  knowledge of that person (or                                             
  persons), false                                                          

  or misleading in a particular.                                           
  This may lead to suspension or                                           
  cancellation of the Port Permit                                          
  and the                                                                  

  imposition of other penalties                                            
  under Australian law.                                                    
  ---------------------------------- -- ------- --- ------- --- ------- -- ---

## ATTACHMENT B

+-----------------------------------+----------------------------------+
| ![](media/image4                  | Return completed form to:        |
| .wmf){width="2.307638888888889in" |                                  |
| height="0.9326388888888889in"}    | Port Permit Application          |
|                                   |                                  |
|                                   | Australian Fisheries Management  |
|                                   | Authority\                       |
|                                   | Box 7051\                        |
|                                   | Canberra Mail Centre ACT 2610\   |
|                                   | AUSTRALIA                        |
|                                   |                                  |
|                                   | Telephone +61 2 62725658 *or*    |
|                                   | +61 2 62725106\                  |
|                                   | Facsimile +61 2 62725784\        |
|                                   | E-mail <portpermit@afma.gov.au>  |
+-----------------------------------+----------------------------------+

  -----------------------------------------------------------------------
  **Data Network Identifier (DNID) Download Agreement Form**

  -----------------------------------------------------------------------

  --------------- ----- ------- ------- ------- -- -------------- ---- ----- --- ------- -- ---
  1\. **Vessel                                                                              
  details**                                                                                 

                                                                                            

  Vessel name                                      Vessel type                              

                                                   (e.g.                                    
                                                   longliner)                               

                                                                                            

  IMO number                                       Vessel                                   

                                                   registration                             

                                                                                            

  International                                    Vessel flag                              
  radio call sign                                                                           

                                                                                            

                                                                                            
  --------------- ----- ------- ------- ------- -- -------------- ---- ----- --- ------- -- ---

  --------------- ----- ------- ------- ------- -- ---------- --- ------- --- ------- -- ---
  2\. **Inmarsat                                                                         
  identifiers**                                                                          

                                                                                         

  Serial number                                    Inmarsat                              
                                                   mobile                                

                                                   number                                

                                                                                         
  --------------- ----- ------- ------- ------- -- ---------- --- ------- --- ------- -- ---

  -------------- ----- ------- ------- ------- -- ---------------- --- ------- --- ------- -- ---
  3\.                                                                                         
  **Equipment                                                                                 
  type**                                                                                      

                                                                                              

  Transceiver                                     Model                                       

  manufacturer                                    identification                              

                                                                                              

  Software                                        Inmarsat                                    
  version                                                                                     

                                                  type                                        

                                                                                              
  -------------- ----- ------- ------- ------- -- ---------------- --- ------- --- ------- -- ---

  -------------- ----- ------- ------- ------- -- ------- ----------- ------- --- ------- -- ---
  4\.                                                                                        
  **Authority to                                                                             
  pass emergency                                                                             
  contact                                                                                    
  details to the                                                                             
  Australian                                                                                 
  Maritime                                                                                   
  Safety                                                                                     
  Authority                                                                                  
  (AMSA)**                                                                                   

                                                                                             

  In the event                                                        Yes         No         
  of an Inmarsat                                                                             
  distress alert                                                                             
  being sent                                                                                 
  from                                                                                       

  this                                                                                       
  transceiver, I                                                                             
  give AFMA                                                                                  
  permission to                                                                              
  pass to                                                                                    

  AMSA the                                                (if yes,                           
  contact                                                 please fill                        
  details listed                                          out contact                        
  on the                                                  details on                         
  Distress Alert                                          the                                

  Contact                                                 Distress                           
  Details Form                                            Alert                              
                                                          Contact                            
                                                          Details                            
                                                          Form                               
                                                          attached)                          

                                                                                             
  -------------- ----- ------- ------- ------- -- ------- ----------- ------- --- ------- -- ---

  ------------------------------------------------------------------- ----- -------------------------------------------------------- ------ ------- -- ------------------------------------------------------ --- ------- --- ------- -- ---
  5\. **Declaration**                                                                                                                                                                                                                    

                                                                                                                                                                                                                                         

  I,                                                                                                                                                                                                                                     
  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,                                                                                                                                                                      
  the owner of the Inmarsat transceiver identified above give Telstra                                                                                                                                                                    

  Australia permission to download the Australian Fisheries                                                                                                                                                                              
  Management Authority\'s DNID into the                                                                                                                                                                                                  

  Inmarsat transceiver noted above.                                                                                                                                                                                                      

                                                                                                                                                                                                                                         

                                                                            Owner                                                                      Witness                                                                           

                                                                                                                                                                                                                                         

  Signature                                                                 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                              

                                                                                                                                                                                                                                         

  Printed Name                                                              \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                              

                                                                                                                                                                                                                                         

  Date                                                                      \_\_\_\_/\_\_\_\_/\_\_\_\_                                                 \_\_\_\_/\_\_\_\_/\_\_\_\_                                                        

                                                                                                                                                                                                                                         
  ------------------------------------------------------------------- ----- -------------------------------------------------------- ------ ------- -- ------------------------------------------------------ --- ------- --- ------- -- ---

## ATTACHMENT C

+-----------------------------------+----------------------------------+
| ![](media/image4                  | Return completed form to:        |
| .wmf){width="2.307638888888889in" |                                  |
| height="0.9326388888888889in"}    | Port Permit Applicaton           |
|                                   |                                  |
|                                   | Australian Fisheries Management  |
|                                   | Authority\                       |
|                                   | Box 7051\                        |
|                                   | Canberra Mail Centre ACT 2610\   |
|                                   | AUSTRALIA                        |
|                                   |                                  |
|                                   | Telephone +61 2 62725658 *or*    |
|                                   | +61 2 62725106\                  |
|                                   | Facsimile +61 2 62725784\        |
|                                   | E-mail <portpermit@afma.gov.au>  |
+-----------------------------------+----------------------------------+

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  **Inmarsat Distress Alert Contact Details Form**

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  1\.                                                                                            
  **Vessel                                                                                       
  details**                                                                                      

                                                                                                 

  Vessel name                                                     International                  

                                                                  radio call sign                

                                                                                                 

  Contact           Telephone                        Fax                                         
  details :                                                                                      

                    number                           number                                      

                                                                                                 

                    HF radio                                                                     

                    (frequency)                                                                  

                                                                                                 
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  2\.                                                                                   
  **Vessel                                                                              
  owner\'s                                                                              
  details**                                                                             

                                                                                        

  Name                                         Mobile                                   
                                               telephone                                

                                               number                                   

                                                                                        

  Address                                      Fax number                               

                                                                                        

                                                                                        

                                               E-mail                                   

                                               address                                  

                                                                                        

                                                                                        

  Telephone                                                                             

  number                                                                                

                                                                                        
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  3\.                                                                                   
  **Master\'s                                                                           
  details**                                                                             

                                                                                        

  Name                                           Telephone                              

                                                 number                                 

                                                                                        

  Address                                        Fax number                             

                                                                                        

                                                                                        

                                                                                        

                                                                                        
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