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CPC-2-3-07 - Maritime Mobile Service Identities (MMSIs)

Annex D - MMSI Application Form - Ship Station Group

Part B - Information ( denotes mandatory fields and x denotes mandatory fields if issued or installed):

	Applicant Name: Last, First
	Applicant Telephone Number: (include country code and area code)
	Applicant Mailing/Postal Address: (include postal code)
	Applicant Fax Number: (include country code and area code)
	Applicant Electronic Mail Address:
x	MMSI: Nine digit Maritime Mobile Service Identity beginning with 0316 (mandatory only if previously issued or installed)
	Ship Station Group Name: Name as adopted by the group of vessels
	Ship Station Group Contact Name: Name of the individual representing the group of vessels with respect to radio communication matters
	Ship Station Group Contact Information: (if different from Applicant fields) Full mailing address including postal code:  Telephone (including country code and area code):  Fax:  Email:
	Ship Station Group Contact Vessel Name: Name of the vessel operated by the Ship Station Group Contact individual
	Ship Station Group Contact Vessel MMSI: Maritime Mobile Service Identity of the vessel operated by the Ship Station Group Contact individual
	Emergency Contact Person Ashore Name and Address:
	Emergency Contact Person Ashore Telephone Number:  (include country code and area code)
	Emergency Contact Person Ashore Fax Number: (include country code and area code)
	Additional Information and/or Instructions:

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