Please include three colour photographs of vessel (side view), additional boats used for fishing and additional out-of-water equipment for detecting fish, — an illustration and detailed description of the fishing gear used, — a document proving that the representative of the shipowner is empowered to sign this application. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Date of application) (Signature of representative of shipowner) 31. 1. 98 Appendix 2 FREEZER TRAWLERS EN Official Journal of the European Communities L 25/93 (DEMERSAL SPECIES) Month: Year: Name of vessel: Nationality (flag): Engine power: Gross tonnage: Fishing method: Port of landing: Date Fishing area Number of hours Number of hours fishing Fish species Longitude Latitude Xxxxx 0/ 0/ 0/ 0/ 0/ 0/ 0/ 0/ 0/ 00/ 00/ 00/ 13/ 14/ 15/ 16/ 17/ 18/ 19/ 20/ 21/ 22/ 23/ 24/ 25/ 26/ 27/ 28/ 29/ 30/ 31/ TOTAL (in °C)
Please include. ■ the medical record sign by the physician. ■ the original of all prescription and bills signed by the physician. ■ bank account details. ■ the original detailed account of the settlement made by any other insurance. ■ all original and relevant supporting documents. In case of accident please include : ■ all originals and supporting documents. In case of prior approval : ■ copy of your physician’s prescription. Declaration : I hereby authorise the release of any medical information necessary for the handling of my claim. I declare the above information as accurate and complete to the best of my knowledge. Date : hh hh hhhh Signature of Insured or legal representative Send your claim to : Golden Care – Medical Service 00 Xxxxxxxxx Xxxxxxxxxx - 0000 Xxxxxx - Xxxxxxxxxxx Golden Care SA - Centre de gestion et d’administration médicale et d’assistance
Please include. ◼ One full-size set of drawings and one set of half-size drawings ◼ Legal description and/or other documents describing the area to be encroached upon ◼ Application fee of $600, non-refundable Signature: Date:
Please include. ❑ Mileage (Round Trip) ❑ Event Flyer or E-mail ❑ Registration Form ❑ Travel Agreement* Funding Source** ATTENDEES
