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Telephone
( )_____________________
( )_____________________
( )_____________________
( )_____________________
Area Code
Area Code
Area Code
Area Code
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Telephone
( )_____________________
( )_____________________
( )_____________________
( )_____________________
Area Code
Area Code
Area Code
Area Code
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Telephone
( )_____________________
( )_____________________
( )_____________________
( )_____________________
Area Code
Area Code
Area Code
Area Code
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Home Work
Cellular Fax Other
Owner/Operator Information
Name______________________________________________
Mailing Address ______________________________________
___________________________________________________
City _____________________ State/Province _____________
ZIP (Postal) Code __________ Country ___________________
E-mail ______________________________________________
(Last, First, Middle Initial)
Official 406 MHz EPIRB Registration Form
Category I (Automatic Deployment)
Category II (Manual Deployment)
EPIRB Information
Beacon ID (Unique Identifier Number)
(15 digit character ID provided by EPIRB manufacturer)
Vessel Information
Mail or Fax to:
NOAA/SARSAT
NSOF, E/SP3
4231 Suitland Road
Suitland, MD 20746
Fax No. 301-817-4565
If you have any questions about this form or with EPIRB registration in general, please call 1-888-212-SAVE (7283) or 301-817-4515.
For information on the U.S. Search & Rescue Satellite-Aided Tracking system, please visit: www.sarsat.noaa.gov
EPIRB Information
EPIRB Registration
New EPIRB Registration Replacement of EPIRB Decal
Renewal of EPIRB Registration Check here if this EPIRB is a replacement for a previously registered EPIRB.
Change of EPIRB Information or Ownership Please enter the old EPIRB unique ID number ________________________
Crew and Passengers
Marina/Dock
Usage:
Commercial Non-commercial
Government Military Government Non-military
Type
Sail: Number of Masts ____________________
Power:
Fishing Tug Cargo Tanker Pleasure Craft
Other ____________________
Non-power:
Life Boat Life Raft Other__________________
Vessel Name _____________________________________
Vessel Color____________
Survival Craft(s) on Vessel: Life Boat
_____
Life Raft
_____
Is your EPIRB equipped with a Simplified Voyage
Data Recorder (SVDR)?
Radio Equipment
(Check all that apply)
VHF MF HF SSB Other ___________________
Vessel Telephone Numbers
Radio Call Sign ______________INMARSAT _____________________
Cellular ____________________ MMSI Number ___________________
Federal / State Registration Number __________________
Length Overall (ft) ____________Capacity _____________
Homeport ________________________________________
________________________ ________________________
Additional Data ___________________________________
_________________________________________________
No. of
City State
Emergency Contact Information
(Please indicate someone other than the owner)
Name of Primary 24-Hour Emergency Contact: Name of Alternate 24-Hour Emergency Contact:
__________________________________________________ ________________________________________________
EPIRB Manufacturer __________________________________
Model No. ________________________________________
Signature __________________________________________ Date ____________________________________________
Save Time! Register your beacon online at: www.beaconregistration.noaa.gov
No. of
Yes No
OMB Auth. (0648-0295) Expires: 30JUN2011

Summary of content (2 pages)