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2. Applicant is seeking a license to operate as one of the following:*
   -- Select One --Steamship AgentStevedore

   License Fees
   Stevedore Annual Fee $4,000 / $2,000 after July 1
   Steamship Agent Annual Fee $4,000 / $2,000 after July 1
   
4. Name of Company*
8. Mailing Information
10. Contact Name*
11. Title
13. Mailing Address*
15. Mailing Address 2
17. City*
18. State*
19. Zip*
21. Phone Number*
22. Fax Number
24. Email Address
28. Corporate Officer or Owner’s Information
30. Corporate Officer or Owner’s Name*
31. Title
33. Address 1*
35. Address 2
37. City*
38. State*
39. Zip*
41. Phone Number*
42. Fax Number
44. Email Address
48. Business Information
50. Type of Ownership*
    -- Select One --Sole ProprietorshipPartnershipCorporationJoint Venture
51. Date of Incorporation or Creation*
53. Type of Business to Be Conducted on Premises*
57. If Applicant Is an Individual...
59. If Applicant Is an Individual, Name and Address of Firm Which Applicant Will Conduct Steamship Agency or Stevedore Activities Upon Issuance of License
61. Names, Positions, and Addresses of Principal Officers of Said Firm
63. Names and Addresses of All Individuals And/or Firms Owning Interest, Directly or Indirectly, Together With the Respective Interest Owned, in Such Firm
67. If Applicant Is a Firm...
69. If Applicant Is a Firm, List the Names and Addresses of Individuals Employed by the Firm Who Are Experienced in Steamship Agency or Stevedore Activities
71. List of Licenses, Locations, Terms, Revocations, Suspensions, or Termination for Prior or Existing Steamship Agency or Stevedore Licenses of the Applicant
75. Banking Information
    Do not provide any confidential information on this form, such as account or routing numbers.
77. Has Applicant ever had a bond or letter of credit called due to a claim of default?*

    1. Yes
    2. No
79. Local Bank Name, Address, and Phone Number*
81. List Three Business References Including Names, Addresses, and Phone Numbers:*
83. Number of Vehicles to Work at Port
84. Number of Employees to work at Port
88. Signature
    The applicant agrees that when this application is approved and a permit is granted to abide by all the rules and regulations of the Port of Palm Beach District and all the provisions of the Port of Palm Beach District Tariff, as amended periodically. The provisions of the Steamship Agency instructions and Stevedore instructions are incorporated herein, and by executing the application, the Applicant agrees to be bound thereby. Nothing contained herein shall relieve Applicant or its employees from the obligation to comply with security requirements now existing or hereinafter imposed by the Port of Palm Beach District, Local, State, and Federal Authorities.
90. Name and Title*
91. Date*
93. State Of*
94. County Of*
Leave This Blank:


96. 1. Receive an email copy of this form.
97. Email address

    This field is not part of the form submission.

98. Submit Submit and Print

* indicates a required field