ATFI Historical Registration (Federal Maritime Commission)
This is a Federal Maritime Commission ATFI historical registration (United States). The form provided here is simply a sample of what the actual Form FMC-83A looks like.
APPLICATION FOR A LICENSE
AS AN OCEAN TRANSPORTATION INTERMEDIARY
Name of corporation, partnership or sole proprietorship: ___________________________
License No. (if any): ___________________________
Trade name(s): ___________________________
Number and street: (If a P.O. box, see instructions) ___________________________
Room or suite number: ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number ___________________________
Area code/tax number ___________________________
Country ___________________________
Is this a new address? ____ Yes ____ No
Application for (check as many as applicable and complete the designated Parts for the boxes checked):
[____] new license to operate as an ocean freight forwarder (Parts A, C, D, E, F)
[____] new license to operate as a non-vessel operating common carrier (Parts A, C, D, E, F)
[____] new license to operate as both an ocean freight forwarder and a non-vessel operating common carrier (Parts A, C, D, E, F)
[____] name change (including trade name(s)) (Parts B, F)
[____] license transfer (Parts A, D, E, F)
[____] business structure change (Parts A, D, E, F)
[____] replacement/additional qualifying individual (Parts C, D, F)
[____] other (please specify) ___________________________
PART A GENERAL
To be completed by applicants for an ocean transportation intermediary license, business structure change or license transfer
1. Applicant is:
[____] A sole proprietorship
[____] A partnership
[____] A corporation: Date of Incorporation _______________ (Mo/Day/Yr)
State of Incorporation ___________________________
Applicant's taxpayer identification number (TIN) _____________________
Provide proof of legal name. Corporations must attach "Certificate of Good Standing." If applicant uses a trade name(s), attach "Certificate of Registration for Trade Name(s)" or other proof of trade name.
2. Will applicant conduct ocean transportation intermediary services through branch officials? ____ Yes ____ No If "Yes," how many branch offices? __________________ (If "Yes," please complete Part E.)
3. Has applicant previously held an ocean freight forwarder or ocean transportation intermediary license issued by the Federal Maritime Commission? ____ Yes ____ No (If "Yes," complete items a, b and c.)
a. License No. ___________________________
b. Date issued: ___________________________ (Mo./Day/Yr.)
c. Name under which issued: ___________________________
4. Describe the current business activities of the applicant (for example, custom house broker, NVOCC, air freight forwarder, etc.). If inactive, check here [____]
___________________________
5. Does applicant now share or intend to share office space or expenses with any other person or entity? ____ Yes ____ No (If "Yes," please identify that person or entity and explain the applicant's relationship with this person or entity.)
___________________________
6. Is any person or entity, other than the applicant or its principals, providing financial assistance to the applicant, such as advancing funds or collateral for the surety bond? ____ Yes ____ No If the answer is yes, please identify the entity: ___________________________
7. Has applicant or any of applicant's partners, officials, directors, or stockholders ever:
(1) been found in violation of any shipping or bill of lading statute? ____ Yes ____ No
(2) filed or been involved in a bankruptcy proceeding, other than as a claimant? ____ Yes ____ No
(3) been convicted of a crime, other than traffic violations? ____ Yes ____ No
If the response to any part of this question is "Yes," please attach an explanation.
PART B NAME CHANGE
To be completed by persons requesting approval of a name change or a change, addition or deletion of a trade name
8. New name of corporation, partnership or sole proprietorship. Provide proof of legal name. Corporations must attach "Certificate of Good Standing").
New name: ___________________________
Trade name(s), if any (attach Certificate of "Registration for Trade Name(s)" or other proof of trade name):
___________________________
PART C QUALIFYING INDIVIDUAL
To be completed by applicants for an ocean transportation intermediary license and replacement/additional qualifying individuals
9. Name of proposed qualifying individual: ___________________________
Title: ___________________________
10. Is the proposed qualifying individual an:
Initial Qualifying Individual ____
Additional Qualifying Individual ____
Replacement Qualifying Individual ____ (Name of individual being replaced: ___________________________)
11. Is the qualifying individual a corporate officer or active partner? ____ Yes ____ No (If "Yes," please attach proof of position held.)
12. Length of qualifying ocean transportation intermediary experience (years/months) ___________________________
13. Has the proposed qualifying individuals ever:
(1) been submitted as the qualifying individual for another company? ____ Yes ____ No
(2) been found in violation of any shipping or bill of lading statute? ____ Yes ____ No
(3) filed or been involved in a bankruptcy proceeding, other than as a claimant? ____ Yes ____ No
(4) been convicted of a crime, other than traffic violation(s)? ____ Yes ____ No
(If the response to any part of this question is "Yes," please explain on separate sheet.)
14. Employment history of qualifying individual demonstrating experience in ocean transportation intermediary services (attach separate sheet, if necessary): ___________________________
(a) Employer's name: ___________________________
Dates employed: ____________________ to ______________________
FMC License No. (If applicable): ___________________________
Number and street ___________________________
Room or suite number ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number: ___________________________
Area code/fax number: ___________________________
Name of Supervisor: ___________________________
Type of business: ___________________________
Description of ocean transportation intermediary duties performed:
___________________________
(b) Employer's name: ___________________________
Dates employed: _____________________ to ______________________
FMC License No. (If applicable): ___________________________
Number and street ___________________________
Room or suite number ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number: ___________________________
Area code/fax number: ___________________________
Name of Supervisor: ___________________________
Type of business: ___________________________
Description of ocean transportation intermediary duties performed:
___________________________
15. Identify three (3) persons, unrelated to the qualifying individual or applicant, who have first-hand knowledge of the actual ocean transportation intermediary experience of the qualifying individual.
(a) Name: ___________________________
Title: ___________________________
Employer's name: ___________________________
FMC License No. (If applicable): ___________________________
Number and street ___________________________
Room or suite number ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number: ___________________________
Area code/fax number: ___________________________
Time period when person named above had knowledge of qualifying individual's experience: ___________________________
Nature of business relationship through which person gained first-hand knowledge of the qualifying individual's ocean freight forwarding experience: ___________________________
(b) Name: ___________________________
Title: ___________________________
Employer's name: ___________________________
FMC License No. (If applicable): ___________________________
Number and street ___________________________
Room or suite number ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number: ___________________________
Area code/fax number: ___________________________
Time period when person named above had knowledge of qualifying individual's experience: ___________________________
Nature of business relationship through which person gained first-hand knowledge of the qualifying individual's ocean freight forwarding experience: ___________________________
PART D OWNERSHIP AND AFFILIATIONS
To be completed by applicants for an ocean transportation intermediary license, business structure change, license transfer and, if applicable, changes resulting from personnel changes or replacement/additional qualifying individual
16. Applicant's ownership, directors and stockholders
Name of Officer/Director/Partner/Stockholder/Business Entity ___________________________
Title ___________________________
Percentage of Ownership ___________________________
Name of Officer/Director/Partner/Stockholder/Business Entity ___________________________
Title ___________________________
Percentage of Ownership ___________________________
Name of Officer/Director/Partner/Stockholder/Business Entity ___________________________
Title ___________________________
Percentage of Ownership ___________________________
17. Will applicant, its qualifying individual, or any officer, director, partner, or stockholder have a beneficial interest in shipments moving in the U.S. foreign commerce? ____ Yes ____ No
If "Yes," identify the name and address of each person or entity having a beneficial interest in shipments moving in the U.S. foreign commerce and the nature of such beneficial interest.
___________________________
___________________________
18. Is either applicant or its qualifying individual related to any other entity by reason of ownership, employment, or common officers, directors, or stockholders? ____ Yes ____ No
If "Yes," identify the name and address of each entity related to the applicant or its qualifying individual; the relationship or affiliation to applicant or qualifying individual and the type of business in which such entity is engaged.
___________________________
___________________________
PART E BRANCH OFFICERS
(Detailed information on branch offices)
19. Identify branch office(s) (attach separate sheet, if necessary):
(a) Address of branch office ___________________________
Separately incorporated? ____ Yes ____ No
Number and street ___________________________
Room or suite number ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number: ___________________________
Area code/fax number: ___________________________
(b) Address of branch office ___________________________
Separately incorporated? ____ Yes ____ No
Number and street ___________________________
Room or suite number ___________________________
City or town ___________________________
State ___________________________
ZIP code ___________________________
Area code/telephone number: ___________________________
Area code/fax number: ___________________________
PART F CERTIFICATIONS
Sole Proprietorships Only
I, ___________________________, certify under penalty of perjury ___________________________ (NAME OF SOLE PROPRIETOR) under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or State offense involving the distribution or possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits, either by court order or operation of law, pursuant to 21 U.S.C. 862.
Signature of Sole Proprietor ___________________________
Date ___________________________
I certify that I have received an read a copy of the Commission's ocean transportation intermediary regulations, 46 C.F.R. Part 515, and pertinent sections of the Shipping Act of 1984, as amended by the Ocean Shipping Reform Act of 1998 and the Coast Guard Authorization Act of 1998 (46 U.S.C. app. 1701 et. Seq.), governing the licensing of ocean transportation intermediaries, and that I will abide by all the provisions thereof from this date forward.
I further certify that I have specifically reviewed 46 C.F.R. § 515.42(h) (concerning the operations of licenses which are NVOCCs or which are related to NVOCCs) and 46 C.F.R. § 515.42(i) (concerning the operations of licenses which have a beneficial interest in merchandise exported from the United States by water or which are related to persons with a beneficial interest in merchandise exported from the United States by water).
I further certify that I shall not act as an ocean transportation intermediary as defined in section 3 of the Shipping Act of 1984, as amended by the Ocean Shipping Reform Act of 1998 and the Coast Guard Authorization Act of 1998, or perform ocean transportation intermediary services as defined in 46 C.F.R. Part 515, unless and until applicant is issued a valid ocean transportation intermediary license by the Federal Maritime Commission.
Under penalties of perjury, I declare that I have examined this application and to the best of my knowledge and belief, it is true, correct, and complete.
Signature ___________________________
Title ___________________________
Date ___________________________