Form FMC-65 Foreign-Based Unlicensed NVOCC Registration/Renewal

Form FMC-65 Foreign-based Unlicensed NVOCC Registration/Renewal

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Form FMC-65 OMB No. 3072-____ (Expires _______)

FOREIGN-BASED UNLICENSED NVOCC REGISTRATION/RENEWAL

1. Legal Name of Registrant:

_______________________________________________________________________________

Name listed above must match legal name on official documentation exactly, including punctuation

2. Trade Name(s): _________________________________________________________________

3. Principal Place of Business Address - number, street, and room or suite number:

_________________________________________________________________________________

City or town, and Country (include applicable postal codes)

4. Telephone Number (include country code): Fax Number (include country code):

_______________________________________________________________________________

5. Name of Contact Person: Email Address of Contact Person:

_______________________________________________________________________________

6. Legal Agent for Service of Process in the U.S.:

Name of Agent:

_______________________________________________________________________________

Address - number, street, and room or suite number:

______________________________________________________________________________

City or town, state, and zip code:

________________________________________________________________________________

Telephone Number: Fax Number:

_________________________________________________________________________________

Name of Contact Person: Email Address of Contact Person:

______________________________________________________________________________

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Form FMC-65 OMB No. 3072-____ (Expires _______)

CERTIFICATION

I certify that I have read a copy of the Federal Maritime Commission’s ocean transportation intermediary regulations, 46 CFR 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. 40101 et seq.), governing ocean transportation intermediaries, and that I will abide by all the provisions thereof from this date forward.

I further certify that I shall use a licensed ocean transportation intermediary for any ocean transportation intermediary activities performed on my behalf in the United States.

Under penalties of perjury, I declare that I have examined this registration and to the best of my knowledge and belief, it is true, correct and complete.

Note: Certification must be executed by the sole proprietor if registrant is a sole proprietorship, by all partners if registrant is a partnership, by a corporate officer if registrant is a corporation, or by a member if registrant is a limited liability company.

___________________________________

Signature

___________________________________

Name

___________________________________

Title

___________________________________

Date