United States 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 $25.00 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)             /           /______