Department of
For Office Use Only
Marine Safety
Change of Name and Address
The information you supply on this form may be disclosed to other government agencies where provided for in legislation.
NEW DETAILS (Documentary evidence supporting Change of Name must be provided)
Surname/Company Name: Motor Driver’s License Number:
Other Names in Full: Date of Birth (dd/mm/yyyy):
Residential Address (Compulsory – Not a PO Box):
Suburb or Town: Postcode:
Phone: Mobile: Email:
Postal Address (Leave blank if same as above):
Suburb or Town: Postcode:
I consent for the Department of Transport (DoT) to use the above address(es) for all DoT dealings?
Yes No
PREVIOUS DETAILS (to be completed when a Change of Name or Address is required)
Surname/Company Name:
Other Names in Full:
Residential Address (Details Compulsory):
Suburb or Town: Postcode:
BUSINESS WITH MARINE SAFETY (Please list all the business areas where you have dealings)
Private Recreational Boat
Registration Number:
Recreational Skipper’s Ticket
Ticket Number:
Location: Mooring Number:
Jetty Licence
Location: Jetty Number:
For Domestic Commercial Vessels or Certificate of Competency/Proficiency please refer to AMSAs website:
I hereby declare that the above information contained in this form is, to the best of my knowledge, true and correct.
Signature/s: ___________________________________________________________________ Date:_____/____ / _____
Document supporting change of name attached
Yes No
Boat Reg RST Mooring Jetties Other:
Receiving Officers Signature: Branch: Date:
Please return this form to the Department of Transport
MS-CONA 0819
When blank, this form is classed as OFFICIAL, when lled out, this form is classed as OFFICIAL-SENSITIVE.
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