CG-719S Small Vessel Sea Service Form

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD

OMB 1625-0040

Small Vessel Sea Service Form

CG - 719S (REV 03/04)

Expires 07/31/2009

PAGE 1

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)

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

Depth (if known)

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
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

February
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

March
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

April
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

May
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

June
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

July
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

August
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

September
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

October
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

November
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

December
(year / days)
_______/_______
_______/_______
_______/_______
_______/_______
_______/_______

Total number of days served on this vessel:

Number of days served on Great Lakes:

Average hours underway (per day):

Number of days served on waters shoreward of the
boundary line as defined in 46 CFR Part 7:
Number of days served on waters seaward of the
boundary line as defined in 46 CFR Part 7:

Average distance offshore:

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).

X Signature of Applicant
NOTE:

•
•

Date

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

X Signature and title of person attesting to experience
Owner’s, Operator’s, or Master’s Name (Last, First Middle):

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

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG - 719S (REV 03/04)

Small Vessel Sea Service Form

OMB 1625-0040

Expires 07/31/2009

PAGE 2
PRIVACY ACT STATEMENT

In accordance with 5 U. S. C. 552a(e)(3), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION
TO THE U.S. COAST GUARD.
1.

AUTHORITY WHICH AUTHORIZED THE SOLICITATION OF INFORMATION:
A. 46 U. S. C. 7302, 7305, 7314, 7316, 7319, AND 7502.
B. SEE 46 CFR PARTS 10 AND 12.

2.

PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED:
A. TO ESTABLISH ELIGIBILITY FOR A MERCHANT MARINER’S LICENSE OR DOCUMENT ISSUED BY THE COAST GUARD.
B. TO ESTABLISH AND MAINTAIN A CONTINUOUS RECORD OF THE PERSON’S DOCUMENTATION TRANSACTIONS.
C. PART OF THE INFORMATION IS TRANSFERRED TO A FILE MANAGEMENT COMPUTER SYSTEM FOR A PERMANENT
RECORD.

3.

THE ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION:
A. TO MAINTAIN RECORDS REQUIRED BY 46 U. S. C. 7319 AND 7502.
B. TO ENABLE ELIGIBLE PARTIES (i.e. the mariner’s heirs or properly designated representative) TO OBTAIN INFORMATION.
C. TO PROVIDE INFORMATION TO THE U.S. MARITIME ADMINISTRATION FOR USE IN DEVELOPING MANPOWER STUDIES
AND TRAINING BUDGET NEEDS.
D. TO DEVELOP INFORMATION AT THE REQUEST OF COMMITTEES OF CONGRESS.
E. TO PROJECT BILLET ASSIGNMENTS AT COAST GUARD MARINE INSPECTION/SAFETY OFFICES.
F. TO PROVIDE INFORMATION TO LAW ENFORCEMENT AGENCIES FOR CRIMINAL OR CIVIL LAW ENFORCEMENT
PURPOSES.
G. TO ASSIST U.S. COAST GUARD INVESTIGATING OFFICERS AND ADMINISTRATIVE LAW JUDGES IN DETERMINING
MISCONDUCT, CAUSES OF CASUALTIES, AND APPROPRIATE SUSPENSION AND REVOCATION ACTIONS.

4.

WHETHER OR NOT DISCLOSURE OF SUCH INFORMATION IS MANDATORY OR VOLUNTARY (Required by law or optional) AND THE
EFFECTS ON THE INDIVIDUAL, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION IS VOLUNTARY,
DISCLOSURE OF THIS INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE MAY RESULT IN NON-ISSUANCE OF THE
REQUESTED DOCUMENT(S).

“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 15 minutes. You may submit any c omments concerning the accuracy of this
burden estimate or any suggestions for reducing the burden to: Commanding Officer, U. S. Coast Guard National Maritime Center, 4200 Wilson Blvd,
Suite 630, Arlington, VA 22203-1804 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.”