Form CG-2633 Application for Waiver and Waiver Order

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-2633 (Rev. 11-07)

APPLICATION FOR WAIVER AND WAIVER ORDER

Form Approved
OMB No. 1625-0002

SECTION I - APPLICATION
NAME OF VESSEL

OFFICIAL NO.

NAME OF OPERATOR

VESSEL’S EMPLOYMENT

WAIVER REQUESTED

EXTENT TO WHICH WAIVER WILL AFFECT SAFETY OF VESSEL

REASONS JUSTIFYING WAIVER

I HEREBY CERTIFY that in my opinion waiver of compliance with the requirements of law or regulation specified above is necessary in the interest of
national defense.
WAIVER REQUESTED FOR PERIOD

DATE

APPLICANT’S TITLE

SIGNATURE

SECTION II – WAIVER ORDER
(To be filled in by Issuing Officer)
IDENTIFICATION DATA (To be filled only if different from information on application)

PERIOD COVERED BY WAIVER

REQUIREMENTS WAIVER

CONDITIONAL PROVISIONS

THIS IS TO CERTIFY that pursuant to the above application a waiver of the requirements of the navigation and vessel inspection laws administered by
the Coast Guard is hereby made effective to the vessel named above in the interest of National Defense to the extent, for the period, and under the
conditions set forth above.
PLACE

TITLE OF ISSUING OFFICER

DATE

SIGNATURE

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 30 minutes. You may submit any comments concerning the accuracy of this burden
estimate or any suggestions for reducing the burden to: Commandant (G-MOC), U.S. Coast Guard, Washington, DC 20593-0001, or Office of Management
and Budget, Paperwork Reduction Project (1625-0002), Washington, DC 20503.
U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-2633 (Rev. 11-07)

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