Location via proxy:   [ UP ]  
[Report a bug]   [Manage cookies]                
Scribd Logo
Upload

Welcome to Scribd!

  • 109 views

    CG 719S

    Uploaded by

    Sr. RZ
    This document contains a small vessel sea service form from the U.S. Coast Guard for applicants seeking credentials to operate vessels under 200 gross tons. The form collects information about the applicant, the vessel, and the applicant's experience including dates served, average hours underway per day, and average distance offshore. The applicant and a certifying owner, operator or master must sign the form verifying the applicant's experience before a credential can be issued.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    CG 719S

    Uploaded by

    Sr. RZ
    109 views2 pages
    This document contains a small vessel sea service form from the U.S. Coast Guard for applicants seeking credentials to operate vessels under 200 gross tons. The form collects information about the applicant, the vessel, and the applicant's experience including dates served, average hours underway per day, and average distance offshore. The applicant and a certifying owner, operator or master must sign the form verifying the applicant's experience before a credential can be issued.

    Original Description:

    CG_719S

    Original Title

    CG_719S

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document contains a small vessel sea service form from the U.S. Coast Guard for applicants seeking credentials to operate vessels under 200 gross tons. The form collects information about the applicant, the vessel, and the applicant's experience including dates served, average hours underway per day, and average distance offshore. The applicant and a certifying owner, operator or master must sign the form verifying the applicant's experience before a credential can be issued.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    109 views2 pages

    CG 719S

    Uploaded by

    Sr. RZ
    This document contains a small vessel sea service form from the U.S. Coast Guard for applicants seeking credentials to operate vessels under 200 gross tons. The form collects information about the applicant, the vessel, and the applicant's experience including dates served, average hours underway per day, and average distance offshore. The applicant and a certifying owner, operator or master must sign the form verifying the applicant's experience before a credential can be issued.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    DEPARTMENT OF HOMELAND SECURITY OMB No.

    1625-0040
    U.S. Coast Guard Exp. Date: 01/31/2016
    SMALL VESSEL SEA SERVICE FORM
    For Service on Vessels Under 200 Gross Tons Only
    Section I: Applicant Information (Note: Complete One Form Per Vessel)
    Name Last First Middle Reference Number (if applicable) Social Security Number

    Vessel Name Official Number or State Registration Number

    Length Width (if known) Depth (if known)


    Vessel Gross Tons Feet Inches Feet Inches Feet Inches

    Propulsion (Motor/Steam/Gas Turbine/Sail/Aux Sail) Served As (Master/Mate/Operator/Deckhand/Engine etc.)

    Name of Body or Bodies of Water Upon Which Vessel was Underway (Geographic Locations)

    Section II: Record of Underway Service


    In the block under the appropriate month, write in the number of days you served for that year (you can show more than one year)

    January February March April


    Year Days Year Days Year Days Year Days

    May June July August


    Year Days Year Days Year Days Year Days

    September October November December


    Year Days Year Days Year Days Year Days

    Total number of days served on this vessel: Number of days served on Great Lakes:

    Number of days served on waters shoreward of


    Average hours underway (per day)?
    the boundary line as defined in 46 CFR Part 7:

    Number of days served on waters seaward of the


    Average distance offshore:
    boundary line as defined in 46 CFR Part 7:

    CG-719S (01/14) Page 1 of 2 Reset


    SMALL VESSEL SEA SERVICE FORM
    Section III: Signature and Verification - Applicant Read Before Signing!
    I certify that I have served on the above vessel as stated. I am making this statement in order that I, the applicant, may obtain a credential to operate a vessel
    under the provisions of Title 46 CFR, as applicable. I understand that if I make any false or fraudulent statement in this certification of service, I may be subject to
    a fine or imprisonment of up to five (5) years or both (18 U.S.C. 1001).

    Signature of Applicant Date (MM/DD/YYYY)

    x
    NOTE: The Owner, Operator, or Master must complete the remainder of this form.
    If you are the owner of the vessel, proof of ownership must be provided.
    Owner, Operator or Master Read Before Signing! I certify that the above individual has served on the above vessel as stated. I am making this statement in
    order that the applicant may obtain a credential to operate a vessel under the provisions of Title 46 CFR, as applicable. I understand that if I make any false or
    fraudulent statement in this certification of service, I may be subject to a fine or imprisonment of up to five (5) years or both (18 U.S.C. 1001).

    Signature and Title of Person Attesting to Experience Date (MM/DD/YYYY)

    x
    Owner's, Operator's, or Master's Name Owner's, Operator's, or Master's address and phone number
    Last First Middle Street Address

    Email Address (Optional) City State Zip Code Phone

    PRIVACY ACT STATEMENT

    Authority: 5 U.S.C. 301; 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7305, 7313, 7314, 7316, 7317, 7319, 7502, 7701, 8701, 8703, 9102; 46 C.F.R. 12.02; 49
    C.F.R. 1.45, 1.46
    Purpose: The principal purpose for which this information will be used is to determine domestic and international qualifications for the issuance of merchant
    mariner credentials. This includes establishing eligibility of a merchant mariner's credential, duplicate credentials, or additional endorsements issued by the
    Coast Guard and establishing and maintaining continuous records of the person's documentation transactions.
    Routine Uses: The information will be used by authorized Coast Guard personnel with a need to know the information to determine whether an applicant is a
    safe and suitable person who is capable of performing the duties of the Merchant Mariner. The information will not be shared outside of DHS except in
    accordance with the provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).
    Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in non-issuance of
    the requested credential.

    An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.
    The United States Coast Guard estimates that the average burden for this report is 15 minutes. You may submit any comments concerning the accuracy of this
    burden estimate or any suggestions for reducing the burden to: Commanding Officer, U. S. Coast Guard National Maritime Center, 100 Forbes Drive,
    Martinsburg, WV 25404 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.

    CG-719S (01/14) Page 2 of 2 Reset

    You might also like