Fmc 18 Form – Fill Out and Use This PDF

Form FMC-18 (Rev. 10/07)

OMB NO. 3072-0018 (Expires 02/28/2014)

APPLICATION FOR A LICENSE AS AN OCEAN TRANSPORTATION INTERMEDIARY

FOR USE IN PREPARING

FORM FMC-18

(Rev. October 2007)

FEDERAL MARITIME

COMMISSION

I

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE

General--The information contained in this notice is required to be provided pursuant to Public Law 93-579 (Privacy Act of 1974) 5 U.S.C. 552a, as amended, for individuals completing Form FMC-18 Rev. "Application For A License as an Ocean Transportation Intermediary."

Authority--Sections 15, 17, and 19 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. 1714, 1716 and 1718), and section 4 of the Administrative Procedure Act (5 U.S.C. 553) authorize and direct the Federal Maritime Commission to make rules and regulations affecting licensing, activities, obligations and responsibilities of ocean transportation intermediaries engaged in carrying on the business of a transportation intermediary in oceanborne foreign commerce of the United States. Pursuant to that authority, the Commission has published in 46 CFR Part 515, regulations and forms to implement section 19 of the Shipping Act of 1984, as amended by the Ocean Shipping Reform Act, with respect to the eligibility and procedure for licensing an ocean transportation intermediary. To obtain a license pursuant to 46 CFR Part 515, the information required by Form FMC-18 Rev. must be provided.

Principal Purpose - The primary purpose for the information requested in Form FMC-18 Rev., is to assist in determining whether an applicant for a license as an ocean transportation intermediary meets the necessary qualifications set forth in 46 CFR Part 515 to be eligible for such a license. After a license is granted, this information is also needed for the purpose of monitoring the activities and status of licensees to ensure they are in compliance with statutory requirements and Commission regulations.

Routine Use - All of the information in Form FMC-18 Rev. may be disclosed for routine use by the agency, as provided in System of Records FMC-7, 72 FR 30009. Where there is an indication of a violation, or potential violation of law, or regulatory requirements, the Agency may also disclose information to the appropriate federal, state or local Agencies.

Disclosure of the requested information including the Social Security number SSN is voluntary. The SSN will be

used as an identifier in conducting a background investigation. Failure to provide any or all of the information requested may result in the FMC’s inability to conduct the background investigation as required prior to the issuance

of a license.

THE TIME IT TAKES TO PREPARE YOUR APPLICATION

According to the Paperwork Reduction Act of 1995, as amended, persons are not required to respond to a collection of information unless it displays a valid OMB control number. The valid control number for this information collection is 3072-0018. The time required to complete this information collection is estimated to average 2 hours per response, including the time to review instructions, research existing data resources, gather the data needed, and complete and review the information collection.

II

FILING INFORMATION

I.BEFORE PROCEEDING

You should familiarize yourself with the rules and regulations pertaining to ocean transportation intermediaries OTI . These rules and regulations are contained in section 1 of the Shipping “ct of 1 4, as

amended by the Ocean Shipping Reform Act of 1998 and the Coast Guard Authorization Act of 1998, and 46 C.F.R.

Part 515 of the Commission's regulations that explains the Licensing and Financial Responsibility Requirements. The section also explains the General Duties for OTIs. Copies of these documents may be obtained from the FMC’s Bureau of Certification and Licensing ”CL or can be found on the Commission’s website www.fmc.gov.

Failure to comply with these rules and regulations may result in denial, revocation or suspension of an ocean transportation intermediary license. Persons operating without the proper license may be subject to civil penalties not to exceed $6,000 for each violation. If the violation is willfully and knowingly committed, in which case the amount of the civil penalty may increase to $30,000 for each violation.

Where To Get Forms

You may obtain copies of the Form FMC-18 and the related Surety Bond Form FMC-4 , at the Commission’s website, www.fmc.gov, or by writing to the Federal Maritime Commission, Bureau of Certification and Licensing, 800 North Capitol Street N.W., Washington, D.C. 20573-0001. You may also telephone BCL, Office of Transportation Intermediaries, at (202) 523-5843 or fax at (202) 566-0011.

Where To Get Help

You may contact BCL any time during normal working hours (8:30 am - 5 pm, EST) by telephone at (202) 523-5843 (Office of Transportation Intermediaries) or by fax at (202) 566-0011.

II. COMPLETING THE FORM

The Form FMC-18, including any attachments, must be submitted in duplicate with all applicable Parts completed. If a question within a Part is not applicable, write "N/A". Incomplete applications will be returned without processing.

ALL APPLICATIONS REQUIRE THE COMPLETION OF PARTS A AND G. Other Parts of the FMC-18 must be completed depending on the particular transaction as follows:

Application for	Parts
Initial application for a license	A B D E F G
License transfer	A B C E F G
Business structure change	A B E F G
Name Change	A C G
Replacement or additional qualifying individual	A D E G
Addition of NVOCC or OFF License	A F G
Addition or Removal of Trade Name	A C G

III

All Applications must be typed, no hand written submissions will be accepted. If additional space is needed to respond to Parts B, D, or E, please photocopy the appropriate page and continue entering the information. Clearly mark supplemental pages 1A, 2B, etc. In any other instance where it is necessary to attach a supplemental sheet, please label the supplemental response to match the item number on the application, e.g. Part B, Question No. 7.

PART A - NAME AND ADDRESS

The complete legal name of the applicant must be shown in this section. If this is an application for a name change or license transfer, please enter the name of the applicant and complete the section C titled Name Change/License Transfer to indicate old name or transferor. A document supporting the legal business name must be attached to the Form FMC-18 with the initial application. Documentation is also required for applications seeking approval of a change in business structure, license transfer, name change, or addition of a trade name, See Part B. All applications must contain a street address indicating the principal place of business (must be the physical address of applicant). Post office boxes are not acceptable as a business address, but may be used for receipt of mail.

A license number should be provided only by those persons who are already licensed. An applicant that previously held an OTI license that was revoked or surrendered, must complete Question No. 3, Part B.

Line By Line Instructions

PART B - BUSINESS INFORMATION

1.Check the appropriate box that applies to the applicant. For corporations, the Articles of Incorporation and minutes of a meeting appointing officers (or other documentation that lists all appointed officers) must be submitted with the application. A "Certificate of Good Standing", issued within 6 months from the date of application, is also needed for any corporation that has been in existence for more than one year. Documentation supporting the use of a trade name must be submitted with an initial application or where the application seeks a change in business

structure, license transfer, or name change. For use of more than one trade name, documentation is needed stating which name will be used with the Ocean Freight Forwarder OFF ) and Non-Vessel-Operating Common Carrier

NVOCC licenses.

2.If the applicant is going to conduct OTI business through branch offices in the US or open up a US branch office, this question must be answered in the affirmative and the number of branch offices indicated. If you answered in the affirmative, complete Part F.

3.If the applicant ever held a license as an ocean transportation intermediary (OFF or NVOCC), or if this is an application for a license transfer, this question must be completed. (For license transfers, the information will be that of the transferring licensee.)

4.Describe applicant's current business activities, e.g. export shipper, steamship agent, air freight forwarder, NVOCC, etc. If applicant is currently licensed as an ocean freight forwarder or an NVOCC, please include your license and bond numbers.

5.If applicant intends to share office space or is currently sharing space with another person or firm, please identify the person/firm and explain the relationship, e.g. parent company, no affiliation-paying rent, sister company with common stock ownership, etc.

6.Identify any person or entity (other than a bank or finance company) who is providing financial assistance to the applicant including anyone who is providing collateral for the surety bond.

7.Check all the boxes that apply. If the response to any question is yes, please attach an explanation.

IV

PART C - NAME CHANGE / LICENSE TRANSFER

8.If you are changing the name of your existing company, the new name of the company should appear here. If you are changing your existing corporation’s business structure do not fill out this section. “n official document

supporting the legal name shall be attached to the Form FMC-18. For corporations, an Amended Articles of Incorporation is needed. For LLPs and LLCs, an Amended Partner Membership Agreement can be used.

If you are changing your trade name or adding a trade name, you must attach the appropriate documentation supporting that name (e.g. A Fictitious Name Statement). If you are deleting a trade name, clearly specify the name being deleted.

If you are transferring a license, state the name of the existing company whose license is being transferred from transferor and identify the company which will receive the license transferee . State if all or part of the

company is being transferred (if only part is being transferred list the parts). Provide an explanation of the business practices of both companies. If the transferor will no longer operate as a business provide dissolution papers.

PART D - QUALIFYING INDIVIDUAL

9.Identify the name and title of the proposed qualifying individual for the applicant. Only the following individuals may be a qualifying individual:

Business Structure	Qualifying Individual
Sole proprietor	Applicant
Partnership	Active managing partner
Corporation	Active corporate officer
Limited Liability Company	Active partner or officer

If applicant is proposing more than one qualifying individual complete Part D for each individual. Use a different letter for each qualifying individual (i.e., A5, A6, A7, B5, B6, B7, etc...).

10.Check all the boxes that apply. If replacing a qualifying individual, list the name of the individual being replaced.

11.Check the box that applies. If the qualifying individual is a corporate officer or partner, attach documentation that will verify that fact, e.g. a copy of the corporate minutes electing the qualifying individual or the partnership agreement.

12.Show the total number of years and months of ocean transportation intermediary experience that the qualifying individual is submitting for consideration. The qualifying individual must have a minimum of three years experience in the ocean transportation intermediary business in the United States in order to be approved. (See 46 C.F.R. §§ 515.2(i), 515.2(l), and 515.11(a).)

13.Check the boxes that apply. If the response to any question is yes, please attach an explanation.

14.Show the employment history of the qualifying individual only as it relates to those jobs where experience

was gained in the ocean transportation intermediary business in U.S. foreign commerce. (Qualifying Individuals for NVOCC’s not in the US may submit proof of OTI experience obtained outside the US. To insure that those work

experiences qualify, it is suggested that you review 46 C.F.R. §§ 515.2(i) and (l) of the Commission's rules. Examples of work experience that are not considered acceptable include experience gained overseas (import) as an ocean freight forwarder, or in air freight forwarding, custom house brokerage, or motor freight forwarding.

V

15.Identify three persons, unrelated to the qualifying individual or applicant, who can verify the duties performed by the qualifying individual. The Commission may contact these persons to verify the information set forth on the Form FMC-18.

PART E - OWNERSHIP AND AFFILIATIONS

16.Sole proprietorships must show the name of the owner. Partnerships or similar entities must list the name of the partners or members. Corporations must list the name and title of each officer, director, or stockholder and the percentage of ownership.

17.Identify whether applicant, qualifying individual, other officer, director, partner, member, stockholder, parent or holding company will have a beneficial interest in shipments moving in the United States commerce as defined in

46C.F.R. §§ 515.2(b).

18.Please list any organization or entity of any type whether in the United States or abroad that is affiliated with the applicant. An affiliation is deemed to exist if any person listed in Question 16 is an officer, director, partner, member, owner, stockholder, parent or holding company, or an employee of any other firm in the United States or abroad. Indicate all entities of any type whether in the United States or abroad that is related to the applicant in any other way (e.g., where the applicant holds stock in another entity).

Applicants that are members of large organization or are affiliated with international conglomerates must submit a list of all subsidiaries and affiliations printed in the group's annual report. Holding company’s identify

affiliations that are involved with foreign water borne commerce.

PART F - BRANCH OFFICES

19.Identify all US branch offices of the applicant that perform OTI services. Incorporated branch offices must be separately licensed. If you need additional space, enter the information on supplemental pages.

If the applicant is an NVOCC not in the US, it needs to establish a qualifying office in the US. This office is to be listed in Part F. Branch offices outside the US are not required to be listed.

PART G - CERTIFICATIONS

20.The Form FMC-18 is not considered a valid application unless it is signed. The application must include the title of the individual signing the application and the date of execution. Sole proprietors should also complete the Certification at the top of Page 10 pertaining to the distribution or possession of a controlled substance.

Fees

Following is a list of the fees required to be submitted with various types of applications:

New license	$ 825
License transfer	525
Business structure change	525
Name Change	525
Replacement or additional qualifying individual	525
Addition of NVOCC or OFF license	525

VI

All payments may be made by money order, certified check, cashier's check, or personal check made payable to the Federal Maritime Commission. Please do not send cash. Failure to include the proper fee with your

application will cause it to be returned without processing. It should be noted that fees will not be returned in any instance where the application has been processed in whole or part.

Before Filing Your Application

Please check the application to make certain that all applicable parts have been completed and all questions answered or noted "N/A" within those Parts. Attach all supporting documentation (e.g. proof of legal name) and include the proper fee. Should you have any questions, please call BCL, Office of Transportation Intermediaries at (202) 523-5843 before filing your application.

Where To File

Mail or courier the completed application Form (FMC-18) to the Federal Maritime Commission, Bureau of Certification and Licensing, 800 North Capitol Street N.W., Washington, D.C. 20573-0001.

Change In Facts

Any change in the facts contained in the Form FMC-18 must be reported to the Commission within 30 days of the change. If this is an initial application for a license, the change should be reported as soon as possible to preclude any processing delay that may occur due to the change. There is no fee for filing changes to pending applications.

III.WHAT TO EXPECT

Generally, you can expect to receive notification that your application has been processed and a decision made within 45 days from receipt of the application, assuming the application is complete and our investigation does not reveal any circumstances that would preclude licensing. Incomplete applications will usually be returned within a week. You can also expect the Commission to contact the references for the qualifying individual(s).

Proof of Financial Responsibility

The applicant must obtain proof of financial responsibility upon notification by the Commission that the application for a license as an ocean transportation intermediary has been approved. A license will be issued after the Commission has received acceptable proof of financial responsibility in the form and amount prescribed in 46 C.F.R. §

515.21of the Commission's ocean transportation intermediary regulations. The name of the principal on the proof of financial responsibility must match exactly the legal name of the applicant including abbreviations and punctuation.

If more than six (6) months lapse between the date of notification of approval of an application and receipt of the proof of financial responsibility, the Commission will, at its discretion, undertake a supplementary investigation to determine the continued qualification of the applicant. The fee for such supplementary investigation is $225. Should applicant fail to file the requisite proof of financial responsibility within two years of the date of approval, the Commission will consider the application to be void.

FORM FMC 18 (REV. 10/07)

1

	Form FMC-18	APPLICATION FOR A LICENSE		OMB No. 3072-0018
	(Rev. October 2007)	AS AN OCEAN TRANSPORTATION INTERMEDIARY		(Expires 02/28/2014)
	Federal Maritime
	Commission
	PART A	GENERAL
		TO BE COMPLETED BY ALL APPLICANTS
APPLICATION MUST BE TYPED
a. Name of corporation, partnership or sole proprietorship:			|License No. (if any)

b.Trade name(s):

[ ] Trade name used for NVOCC services only

[ ] Trade name used for OFF services only

[ ] Trade name used for both services

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

d.City or town, state, ZIP code, and country:

e. (Area code)telephone number:

(Area code)fax number:

f.E-Mail address/URL of Contact Person or QI:

g. Is this a new address? [ ]Yes [ ]No

h.Mailing address if different from principal place of business (P.O. Boxes may be used):

City or town, state, Zip code, and country:

i.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, B, D, E, F, G)

[] new license to operate as a non-vessel-operating common carrier (Parts A, B, D, E, F, G)

[] new license to operate as both an ocean freight forwarder and a non-vessel-operating common carrier (Parts A, B,

D, E, F, G)

[] name change (Parts A, C, G)

[] addition / removal of trade name(s) (A, C, G)

[] replacement/additional qualifying individual (Parts A, D, E, G)

[] business structure change (Parts A, B, E, F, G)

[] license transfer (Parts A, B, C, E, F, G) Current name to

[] adding NVOCC services to active OFF license (A, F, G)

[] adding OFF services to active NVOCC license (A, F, G)

All questions within applicable parts must be answered or noted "N/A."

FORM FMC 18 (REV. 10/07)		2
	PART B	BUSINESS INFORMATION

TO BE COMPLETED BY APPLICANTS FOR AN OCEAN TRANSPORTATION INTERMEDIARY LICENSE, BUSINESS

STRUCTURE CHANGE, LICENSE TRANSFER, OR ADDITION OF OFF OR NVOCC SERVICE

1.Applicant is:

[ ] A Sole Proprietorship

[ ] A Partnership

[] A Limited Liability Partnership (LLP): State of Formation

[] A Limited Liability Company or Corporation: State of Formation

[ ] A Corporation: Date of Incorporation		/	/		State of Incorporation
	Mo.		Da.	Yr.

Applicant’s Taxpayer Identification Number (TIN) or Employer Identification Number (EIN)

Provide proof of legal name. All Corporations must attach a copy of their Articles of Incorporation. If the corporation is more than a year old, a "Certificate of Good Standing" issued within 6 months from date of application must be attached. LLPs must attach Partnership Agreements. LLCs must attach Articles of Formation. If applicant uses a trade name(s), attach "Certificate of Registration for Trade Name(s)" or other official proof of trade name.

2. Will applicant conduct ocean transportation intermediary services through branch office(s) in the U.S.? [ ]Yes [ ]No

If "Yes," how many branch offices?

(If "Yes," please complete Part F.)

3.Has applicant previously held an ocean transportation intermediary license (ocean freight forwarder or NVOCC) issued by the

Federal Maritime Commission? [		]Yes [	]No (If “Yes” complete items a, b, and c.)
Or Is this application for a license transfer?			[	]Yes [ ]No (If "Yes," complete items a, b and c on behalf of the company
being transferred.)
a. License No.:	|b. Date Issued:			|c. Name Under Which Issued:
	|	/	/	|
	Mo.	Da.		Yr.

4.Describe the current business activities of the applicant and list any related licenses (including license numbers) and certificates (for example, customhouse broker, NVOCC, air freight forwarder, etc.). If business is not currently conducting any activities,

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 person or entity and explain the applicant's relationship with this person or entity.

FORM FMC 18 (REV. 10/07)

3

7.Has applicant or any of applicant’s partners, officers, directors, or stockholders ever:

(1)	been found in violation of any shipping act?	[	]Yes	[	]No
	or paid penalty in settlement of?	[	]Yes	[	]No
(2)	filed or been involved in a bankruptcy proceeding, other than as a claimant,
	been declared bankrupt, been subject to a tax lien, or had legal judgment
	rendered for a debt?	[	]Yes	[	]No
(3)	been ARRESTED, CHARGED, CONVICTED OF, OR FORFEITED COLLATERAL
	for any FELONY, MISDEMEANOR, OR OTHER VIOLATION?	[	]Yes [		]No
	(Omit: 1. traffic violations for which a fine of $250 or less was paid;
	2. any incident which happened before each persons 21st birthday.)

If the response to any part of this question is “Yes,” please attach an explanation. For bankruptcy, please include order of discharge. For tax lien, please provide release of lien. For judgment, please provide satisfaction of civil judgment.

FORM FMC 18 (REV. 10/07)		4
	PART C	NAME CHANGE / LICENSE TRANSFER

TO BE COMPLETED BY PERSONS REQUESTING APPROVAL OF A NAME CHANGE,

ADDITION OR REMOVAL OF A TRADE NAME,

OR TRANSFER OF A LICENSE

8.Previous name of licensee.

New name of licensee. Provide documentation for name change. (See Instructions)

Trade name(s), if any (attach “Fictitious Name Statement” or other proof of trade name registration):
[	] NVOCC	[	] OFF	[	] Both
[	] NVOCC	[	] OFF	[	] Both
License Transfer:
Name of Transferor
Name of Transferee
Did the transferor sell all of the company to the transferee?						[	] Yes	[	] No
(If no, list the parts that were sold to the transferee)
Is the transferor still operating as a company?						[	] Yes	[	] No
(Provide explanation of business practices for both company’s. If the

company is no longer operating provide dissolution papers.)

FORM FMC 18 (REV. 10/07)

5

PART DQUALIFYING INDIVIDUAL

TO BE COMPLETED BY APPLICANTS FOR AN OCEAN TRANSPORTATION INTERMEDIARY LICENSE
AND REPLACEMENT/ADDITIONAL QUALIFYING INDIVIDUALS
9. Name of proposed qualifying individual:	Title:

Business address: number, street, and room or suite number, city, state, zip code, country (If different from principal address)

	S. S. Number:		DOB	Place of Birth:		US
			Citizen or Resident Alien:
					city, state, county
			(If Resident Alien provide No.)
10. Is the proposed qualifying individual a (an):
	Initial Qualifying Individual	[	]
	Additional Qualifying Individual	[	]
	Replacement Qualifying Individual	[	](Name of individual being replaced:				)

11.	Position the qualifying individual holds as a corporate officer, member, or active partner:		__
	(Attach proof of position held i.e., minutes from meeting electing the officers)
12.	Length of qualifying ocean transportation intermediary experience (years/months):		__
13.	Has the proposed qualifying individual(s) ever:

(1)	been submitted as the qualifying individual for another company?	[	]Yes	[	]No
(2)	been found in violation of any shipping act?	[	]Yes	[	]No
	or paid penalty in settlement of?	[	]Yes	[	]No
(3)	filed or been involved in a bankruptcy proceeding, other than as a claimant,
	been declared bankrupt, been subject to a tax lien, or had legal judgment
	rendered for a debt?	[	]Yes	[	]No
(4)	been ARRESTED, CHARGED, CONVICTED OF, OR FORFEITED COLLATERAL
	for any FELONY, MISDEMEANOR, OR OTHER VIOLATION?	[	]Yes [		]No

(Omit: 1. traffic violations for which a fine of $250 or less was paid;

2. any incident which happened before each persons 21st birthday.)

If the response to any part of this question is “Yes,” please attach an explanation. For bankruptcy, please include order of discharge. For tax lien, please provide release of lien. For judgment, please provide satisfaction of civil judgment.

14.Employment history of qualifying individual demonstrating experience in ocean transportation intermediary services (attach separate sheet, if necessary):

(a)	Employer's name:		Dates employed:(Month/Year)
				to
		Number, street, and room or suite number:		FMC License No. (If applicable):
		City or town, state, and ZIP code:
		Area code/telephone number:	Area code/fax number:	Email address:
		Name of Supervisor:		Type of business:

Description of ocean transportation intermediary duties performed:

FORM FMC 18 (REV. 10/07)			6
(b)	Employer's name:	Dates employed:(Month/Year)
			to
	Number, street, and room or suite number:		FMC License No. (If applicable):
	City or town, state, and ZIP code:
	Area code/telephone number:	Area code/fax number:	Email address:
	Name of Supervisor:		Type of business:

Description of ocean transportation intermediary duties performed:

(c)	Employer's name:	Dates employed:(Month/Year)
			to
	Number, street, and room or suite number:		FMC License No. (If applicable):
	City or town, state, and ZIP code:
	Area code/telephone number:	Area code/fax number:	Email address:
	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:
	Number, street, and room or suite number:
	City or town, state, and ZIP code:
	Area code/telephone number:	Area code/fax number:	Email address:

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.

FORM FMC 18 (REV. 10/07)			7
(b) Name:			Title:
	Employer's name:
	Number, street, and room or suite number:
	City or town, state, and ZIP code:
	Area code/telephone number:	Area code/fax number:	Email address:

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.

(c)	Name:			Title:
		Employer's name:
		Number, street, and room or suite number:
		City or town, state, and ZIP code:
		Area code/telephone number:	Area code/fax number:	Email address:

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.

FORM FMC 18 (REV. 10/07)

9

	PART F			U.S. BRANCH OFFICES
			(DETAILED INFORMATION ON BRANCH OFFICES)
19.		Identify U. S. branch office(s) (attach separate sheet, if necessary):				If none, check here [ ]
	(a) Address of Branch Office:					Separately Incorporated:
					[	]Yes	[ ]No
			Number, street, and room or suite number:
			City or town, state, and ZIP code:
			Area code/telephone number:		Area code/fax number:
	(b) Address of Branch Office:					Separately Incorporated:
					[	]Yes	[ ]No
			Number, street, and room or suite number:
			City or town, state, and ZIP code:
			Area code/telephone number:		Area code/fax number:
	(c) Address of Branch Office:					Separately Incorporated:
					[	]Yes	[ ]No
			Number, street, and room or suite number:
			City or town, state, and ZIP code:
			Area code/telephone number:		Area code/fax number:
	(d) Address of Branch Office:					Separately Incorporated:
					[	]Yes	[ ]No
			Number, street, and room or suite number:
			City or town, state, and ZIP code:
			Area code/telephone number:		Area code/fax number:
	(e) Address of Branch Office:					Separately Incorporated:
					[	]Yes	[ ]No
			Number, street, and room or suite number:
			City or town, state, and ZIP code:
			Area code/telephone number:		Area code/fax number:

FORM FMC 18 (REV. 10/07)			10
	PART G		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

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ALL APPLICANTS INCLUDING SOLE PROPRIETORS

I certify that I have received and 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. 40101 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 licensees which are NVOCCs or which are related to NVOCCs) and 46 C.F.R. § 515.42(i) (concerning the operations of licensees 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, without 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.

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