Canada Albacore Treaty Account Application

Please fax or mail to: ShipCom LLC

7700 Rinla Avenue

Mobile, AL 36619

Phone: 251-666-5110 Fax # 251-666-8339

A: Personal Information
Last Name:_____________________________ First Name:___________________________ Middle Initial:_____ Address:________________________________________________________________________ City:______________________________ State/Prov.:__________________________________ Country:___________________________ Zip/Postal Code: ______________________________ Country & City codes, code & Tel.#___________________ Fax #:__________________________ E-mail address__________________________ Alternate Contact:___________________________________ Phone #:_________________________
B: Company Information
Full Legal Company Name:__________________________________________________________________ Operating as (trade style):___________________________________________________________ Department(if applicable):___________________________________________________________ Contact:___________________________________ Ext.:_________________________ Address:________________________________________________________________________ City:______________________________ Prov.:__________________________________ Country:___________________________ Zip/Postal Code: ______________________________ Country & City codes, code & Tel.#___________________ Fax #:__________________________ Company e-mail address__________________________ Website:__________________________
C: Vessel Information
Vessel Name:___________________________ Radio Call Sign______________ Registration#_______________________ Country of Registry:______________________ Home Port____________________ MMSI #:_________________
D: Credit Card Information
Credit card information required for all Albacore accounts □ Company credit card □ Personal credit card Type of credit card □ Visa □ MC □ Amex Card number:_________________________________________________ Expiration Date____/____ (mm/yy) Name on card:_________________________________________________ Cardholder signature:_____________________________________________ The Credit Card information I submit herein is true and accurate to the best of my knowledge and belief. Because this ShipCom service is located near Mobile, Alabama and when service is rendered, I am aboard my ship at dock, underway at sea or in the air, I am then unavailable to personally hand sign a Credit Card Charge ticket. Therefore I hereby specifically authorize and furnish my credit card particulars for filing to accommodate subsequent radio link communication expenses incurred on my behalf, including this $47.25 registration fee, to be charged to my Credit Card account by ShipCom, LLC. I understand that my Credit Card statement will reflect charges as being due to ShipCom, LLC.
Authorized name (please print):	Authorized Signature:	Date: (dd/mm/yy) / /______