Form Cg-719s - Small Wessel Sea Service Form

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DEPARTMENT OF

TRANSPORTATION –

OMB-2115-0514

Small Vessel Sea Service Form

U.S. COAST GUARD

CG – 719S (REV 10/02)

AGE

Section I – Applicant Information (Note: Complete One Form per Vessel)

Name (Last, First, MiddIe)

Social Security Number

Vessel Name

Official Number or State Registration Number

Vessel Gross Tons

Length

Width (if known)

Depth (if known)

Propulsion (Motor/Steam/Gas Turbine/Sail/Aux Sail)

Served As: (Master/Mate/Operator/Deckhand/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

May

June

(year / days)

_______/_______

July

August

September

October

November

December

(year / days)

_______/_______

0.0

Total number of days served on this vessel:

Number of days served on Great Lakes:

Number of days served on waters shoreward of the

Average hours underway (per day):

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:

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 license/document 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

•

If you were not the owner, the Owner, Operator, or Master must complete the remainder of this form.

NOTE:

•

If you were the owner of the above vessel, proof of ownership must be provided with this form.

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 license 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

Owner’s, Operator’s, or Master’s Name (Last, First Middle):

Owner’s, Operator’s, or Master’s address and phone number: