1. Name & Contact Details of Applicant:
(COPY OF AUTHORISATION FROM OWNER TO BE ATTACHED, WHEN APPLICANT IS NOT THE OWNER)

ATTACH COPY OF AUTHORISATION (if applicable):

NAME: Owner/Authorised Agent:

NAME OF COMPANY (IF APPLICABLE):

ADDRESS:

MOBILE NUMBER:

TELEPHONE NUMBER:

FAX NUMBER:

EMAIL ADDRESS:

2. Vessel Details:

VESSEL NAME:

PORT OF REGISTRY:

TYPE OF VESSEL:
Cargo ShipFishing VesselPassenger Boat (12 or less passengers)

OFFICIAL NUMBER:

FISHING LETTERS & NUMBER and CALL SIGN:

REGISTERED LENGTH:

LENGTH OVERALL:

SEA AREA/S VESSEL IS ENGAGED IN:

A1A2A3

3. PLACE OF SURVEY (PORT/TOWN):

PREFERRED SURVEY DATE 1:

PREFERRED SURVEY DATE 2:

4. NAME OF LOCAL CONTACT PERSON ON DAY OF SURVEY:

CONTACT MOBILE PHONE NUMBER:

5. PAYMENT DETAILS

ONCE YOU HAVE COMPLETED THE APPLICATION FORM, PLEASE CHOOSE ONE OF THE FOLLOWING PAYMENT OPTIONS:

1 : Electronic Funds Transfer

Account Name: Irish Marine Radio Surveys
IBAN Number: IE53BOFI90544068380994
BIC / SWIFT Address: BOFIIE2D
Bank Name: Bank of Ireland
Bank Address: Stephens St, Sligo

2: Cheque / Bank Draft

Please make Cheque / Bank Draft payable to
" Irish Marine Radio Surveys"

3: Bank Lodgement

Use Bank Lodgement Slip and ensure to enclose Stamped Receipt
(See BIC and IBAN details above)

POST YOUR APPLICATION
Mr James Kelly, Radio Surveyor.
Irish Marine Radio Surveys,
Cartron Hartland,
Kilmore,
Carrick on Shannon
Co. Roscommon
N41 VN25

Please see Marine Radio Survey Application Guidance notes or call me 087 7794149 with any queries

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