APPLICATION FOR DOMINICA VHF RADIO OPERATOR LICENSE

First Name (Given name) *

Middle Initial

Last Name (Family Name) *

Suffix

Date of Birth (DD/MM/YYYY) *

Place of Birth (City and Country) *

Citizenship *

Email *

Confirm Email *

MAILING ADDRESS

The Commonwealth of Dominica Maritime Administration (DMRI) does not provide services to persons who are target of any sanction law, or is located or resident of a country or territory that is, or whose government currently is, the target of countrywide sanctions imposed by any U.S. government sanctions authority. Additionally, DMRI may restrict access to services to individuals in heightened risk countries. If you are unable to access DMRI services due to unavailability of services in your country, please contact mariner@dominica-registry.com for additional information.

Street *

City *

State or Province *

Postal Code *

Country *

Telephone *

Passport Number *

Country of Passport *

Sex *

Male

Female

Photo Upload: Please upload a picture of yourself (color photo) no larger than 5MB that will be printed on your VHF license. Photo should meet passport requirements at 2" x 2" *

Example:

Passport ID Upload: Please upload your "color" passport photo identification page for verification purposes. *

Example:

Signature of applicant *

clear

Date of Application * +

Dominica VHF Marine Radio License Processing Fess - Please choose between standard or expedited processing. *