Form Cg-3300 Department Of Homeland Security - U.s. Coast Guard Application For Permit To Enter Cuban Territorial Seas Page 2

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Section 3 (continued) - Additional names/crew
Name
Birthdate
Address
City
State
Zip
1. ___________________________________
___________
_______________________
___________________
________
__________
2. ___________________________________
___________
_______________________
___________________
________
__________
3. ___________________________________
___________
_______________________
___________________
________
__________
4. ___________________________________
___________
_______________________
___________________
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__________
5. ___________________________________
___________
_______________________
___________________
________
__________
6. ___________________________________
___________
_______________________
___________________
________
__________
7. ___________________________________
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_______________________
___________________
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__________
8. ___________________________________
___________
_______________________
___________________
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__________
9. ___________________________________
___________
_______________________
___________________
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__________
10. __________________________________
___________
_______________________
___________________
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__________
11. __________________________________
___________
_______________________
___________________
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__________
12. __________________________________
___________
_______________________
___________________
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__________
13. __________________________________
___________
_______________________
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14. __________________________________
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_______________________
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15. __________________________________
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_______________________
___________________
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__________
16. __________________________________
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_______________________
___________________
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__________
17. __________________________________
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_______________________
___________________
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__________
18. __________________________________
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_______________________
___________________
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__________
19. __________________________________
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_______________________
___________________
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__________
20. __________________________________
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_______________________
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21. __________________________________
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_______________________
___________________
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__________
22. __________________________________
___________
_______________________
___________________
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__________
23. __________________________________
___________
_______________________
___________________
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__________
24. __________________________________
___________
_______________________
___________________
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25. __________________________________
___________
_______________________
___________________
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26. __________________________________
___________
_______________________
___________________
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27. __________________________________
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_______________________
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28. __________________________________
___________
_______________________
___________________
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USCG Official Use:
Authorization is: GRANTED ________
DENIED _________
USCG Official Signature: ______________________________________________________________ Date: __________________________________
Returned to Applicant on: ____________________ (date) Printed Name & Unit: _________________________________________________________
Privacy Act Notice
General: This notice is provided pursuant to Public Law 93-579, Privacy Act of 1974, 5, U.S.C. Section 552a.
Authority: Collection of this information is authorized by 33 C.F.R. Part 107, implemented under the authority of 50 U.S.C. 191, 50 U.S.C. 192, 50 U.S.C.
194, 50 U.S.C. 195, 14 U.S.C. 141; Presidential Proclamations 6867 and 7757; and Secretary of Homeland Security Order 2004-001.
Purpose: The information is collected as part of a permitting process that is designed to regulate the departure from U.S. territorial waters of U.S. vessels
and vessels without nationality, and entry thereafter into Cuban territorial waters.
Routine Uses: The information will be used by and disclosed to Coast Guard personnel who need the information to process the permit application and to
conduct related to maritime law enforcement activities. The Coast Guard may share the information with other government agencies as necessary to process
permit requests, conduct enforcement activities related to 33 C.F.R Part 107, and to respond to potential or actual threats to maritime safety or security.
Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may delay or prevent granting
of a requested permit.
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 Coast Guard estimates that the average burden for this report is 2 minutes. You may submit any comments concerning the accuracy of this estimate
or any suggestions for reducing the burden to: Commandant (CG-5311), U.S. Coast Guard, 2100 2nd Street, SW, Washington DC 20593-7363.
Fax (202) 372-2913 or Office of Management and Budget, Office of Information and Regulatory Affairs, Washington, D.C. 20503.
Reset
CG-3300 (3/11)
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