ACI marina Pomer, Pomer 26/A, HR-52100 Pula, Tel: +385 52 573 162

ZAHTJEV ZA VEZ REQUEST FOR A BERTH ANFRAGE LIEGEPLATZ RICHIESTA D'ORMEGGIO

IME PLOVILA (S/Y, M/Y, KAT) : ________________________________________________________________________ NAME OF VESSEL BOOTSNAME NOME DELL' IMBARCAZIONE PROIZVOA I MODEL : __________________________________________________________________________________ MAKE & MODEL OF VESSEL HERSTELLER & FAHRZEUGTYP DITTA COSTRUTTRICE E MODELLO DUINA PREKO SVEGA (m) : _____________________________________________________________________________ LENGHT OVERALL LNGE BER ALLES LUNGHEZZA FUORI TUTTO GAZ MAKSIMALNI (m) : ___________________________________________________________________________________ DRAFT TIEFGANG PESCAGGIO GODINA GRADNJE : _______________________________________________________________________________________ YEAR BUILT BAUJAHR ANNO DI COSTRUZIONE ZASTAVA : __________________________________________________________________________________________________ FLAG FLAGGE BANDIERA MATERIJAL GRADNJE : ___________________________________________________________________________________ CONSTRUCTION MATERIAL RUMPFBAUSTOFF MATERIALE DI COSTRUZIONE

VLASNIK PLOVILA : _______________________________________________________________________________________ OWNER OF THE VESSEL EIGENTMER PROPRIETARIO ADRESA : ___________________________________________________________________________________________________ FULL ADDRESS ANSCHRIFT INDIRIZZO TELEFON / FAX / E-MAIL : _________________________________________________________________________________ PHONE N FAX N

ZAHTJEV ZA / REQUEST FOR / ANFRAGE FR / RICHIESTA PER :

a) GODINJI VEZ / ANNUAL BERTH / JRLICHER LIEGEPLATZ / ORMEGGIO ANNUALE b) MJESENI VEZ / MONTHLY BERTH / MONATLICHER LIEGEPLATZ / ORMEGGIO MENSILE

ZAHTJEV ZA PERIOD OD __________________ DO ___________________ REQUESTED PERIOD FROM - TO ANFRAGE FR ZEITRAUM VOM - BIS RICHIESTA PER IL PERIODO DAL - AL

____________________ ______________________ (Datum / Date / Datum / Data) (Potpis / Signature / Unterschrift / Firma)