CERTIFICATE OF COMPETENCY APPLICATION

AMSA 426
Marine Safety (Domestic Commercial Vessel) National Law Act 2012
Marine Order 505 (Certificates of competency – national law) 2022

Master less than 24 m NC Apply for this certificate for the first time

Submitting the form

You must submit your application at a participating Australia Post outlet. There is a list of these outlets on our website. If you are
completing a training course, some registered training organisations can submit your application for you.

If you live in a remote rural location or cannot access a participating Australia Post outlet, please contact AMSA Connect on 1800
627 484 or at amsaconnect@[Link]

You must submit one application form for each certificate of competency. If you are renewing 2 certificates you need 2 application
forms, however you can use the same supporting documents for both applications.

Lodging your application with Australia Post

You must lodge your application in person. Make sure you take your original proof of identity documents with you.

Australia Post will:

• Check your form is complete.

• This includes making sure you have included your middle name(s) (if you have them) and checking that you
have attached the documents listed in the checklist.
• Please do not submit original documents for the items on the checklist.
• Take payment of the application fee.
• Payment may be made by credit card, cash or EFTPOS. Australia Post will provide you with a tax invoice and
attach a payment record to your application.
• The payment record we get is not a tax invoice and we will not be able to provide you with a tax invoice if you
misplace the one provided by Australia Post.
• Take your passport photograph and attach it to your application
• Check you have signed and dated the Declaration and consent.
• Check your identity using our proof of identity requirements, which you can find on our website.
• Submit your application to AMSA.

If you have not fully completed the form and attached all required documents Australia Post may not accept your application and
your application processing may be delayed.

Certificate of competency type Certification application type Application Ref. Date

Master less than 24m NC New 14042612909575 15/08/2023

AMSA Form 426 Page 1 of 5 Version: 11/22

 Application Ref: 14042612909575

PAYMENT
Certificate: Master less than 24m NC Action: New TOTAL FEE PAYABLE: A$174.00

APPLICANT SEAFARER DETAILS

Title Given name(s) Last name

Mr MATIC SANDI

Date of birth (dd/mm/yyyy) Nationality

25/08/1983 Australian

Type of Certificate currently held Certificate Number

Mobile Phone Email (recommended)

0448 800 250 atty@[Link]

Street name and number Town / Suburb

19 POLLARD STREET GLENDALOUGH

State Postcode Country

Western Australia 6016 AUSTRALIA

Delivery address same as street address?

Postal street name and number Town / Suburb

PO box 355 Mt Hawthorn

State Postcode Country

WA 6915 WA

ENDORSEMENT OPTIONS
If you have completed the required sea service, you can apply for an endorsement to be added to your certificate. If you are
applying for an endorsement, you need to submit sea service that matches the endorsement requirement.

I wish to apply for the following endorsement(s):

Endorsement to command and operate the engines of a vehicular ferry-in-chains attached to the shore by cable

INDUSTRY EXPERIENCE – Master less that 24m NC – New

AMSA task book

Yes  No 1. Have you completed an AMSA approved task book for the Master less that 24m NC

Experience (pick one)

Please answer this question if you answered ‘Yes’ to question 1 above
Yes 2. You have at least 120 days qualifying sea service
- On a vessel at Least 7.5m long
- Working in a deck capacity

Please answer this question if you answered ‘No’ to question 1 above

 Yes 3. You have at least 360 days qualifying sea service
- working in deck or both deck and engineering capacity

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 Application Ref: 14042612909575

- at least 180 days on commercial vessels

- at least 7.5m long

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 Application Ref: 14042612909575

ATTACHMENTS – Master less than 24m NC – New

 ACMA Long Range Operator Certificate of Proficiency (or higher)

 Certificate of Medical Fitness - Domestic Seafarers (AMSA 1850)

 Course completion certificate: Master less than 24m NC Certificate 3

 Cover page of completed AMSA Mandated Practical Assessment (AMPA) of the same level as your course.

 First aid certificate (HLTAID011 unit of competency) or equivalent

 Qualifying sea service required for the certificate of competency being applied for. You need to submit at least one of the
following as proof of qualifying sea service:
• Record of Sea Service Form(s) (AMSA 771); or
• The on board sea service record from your task book; or
• A letter from the vessel operator, owner, master or chief engineer detailing your sea service; r
• An approved sea service log book

DECLARATION AND CONSENT

I declare that:
• To the best of my knowledge the information provided by me in this application, and any attachments I have included with
this application, are true and correct.
• I have checked that all the required supporting documents are attached to this application form.
• I understand and acknowledge that a person is guilty of an offence under section 137.1 of the Criminal Code Act 1995 if the
person gives false or misleading information, or omits anything without which the information is misleading, to a
Commonwealth entity, to a person who is exercising powers or performing functions under a law of the Commonwealth, or
in compliance or purported compliance with a law of the Commonwealth.
• I understand that the provision of false or misleading information in this application, and in any attachments I have included
with this application, may result in the revocation of this certificate.
• I consent to the Australian Maritime Safety Authority making all reasonable enquiries in order to verify that the information
provided by me in this application (and any attachments I have included with this application) is true and correct.
• I understand and acknowledge that the Australian Maritime Safety Authority may ask that I provide any information or
document that the National Regulator reasonably considers necessary for consideration of this application.
• I understand and acknowledge that the Australian Maritime Safety Authority may ask another person to provide any
information, document or agreement that is considered reasonably necessary
Declaration Agreement
 I agree to the declaration and provide my consent.

Signature Name Date

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 Application Ref: 14042612909575

HOW TO LODGE
Lodge your completed application and attachments at an AMSA contracted Australia Post outlet. Locations of contracted Australia
Post outlets can be found at [Link].
AMSA Privacy Statement
The collection of information requested in this form is required or authorised by Schedule 1 of the Marine Safety (Domestic
Commercial Vessel) National Law Act 2012 (the Act). It will be used for purposes related to the Act and may be provided to
Commonwealth or State / Territory government agencies for the purposes of marine safety. Failure to provide the information
may result in the transaction not being processed. To contact us, or for more information on how to access or correct your
personal information, how to make a privacy complaint, or how your information may be used or disclosed for purposes beyond
those described in this statement, visit [Link]/privacy/.

Australia Post Privacy Statement

Australia Post is acting as an agent for the Australian Maritime Safety Authority (AMSA). The information requested on this
form is being collected by Australia Post for use by AMSA. Your application will not be able to be processed if you do not
provide this information. Your personal information is managed in accordance with Australia Post’s privacy policy which is
available at [Link]. Australia Post may only disclose the information provided by you if required or authorised by law,
or in accordance with our privacy policy. You may obtain access to your personal information by contacting the Privacy Contact
Officer, Australia Post, GPO Box 1777, Melbourne Vic 3001 or visit [Link].

* 2242 C $174.00 01 4260117 98

PROOF OF IDENTITY
Proof of identity documents must be presented to Australia Post at the time of lodging
your application. These MUST be original documents.

For details of the proof of identity requirements go to [Link].

Your photograph will be taken upon lodgement of your application at Australia Post at no
extra cost to you.

Australia Post to include

photograph with application
Proof of identity verified by Australia Post

Australia Post officer name Australia Post officer signature Date Australia Post location code

/ /

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