CG-7042 Authorization For Credit Card Transactions

DEPARTMENT OF HOMELAND SECURITY

OMB Number: 1625-0027

U.S. Coast Guard
AUTHORIZATION FOR CREDIT CARD TRANSACTIONS

Expiration Date: xx/xx/xx

A. DATE

B. FROM

C. TELEPHONE NUMBER

D. VESSEL NAME

E. HULL IDENTIFICATION # OR OTHER UNIQUE IDENTIFIER (IF ANY)

F. CREDIT CARD HOLDER’S NAME

G. CREDIT CARD NUMBER (WE ACCEPT VISA, MASTERCARD, AMERICAN EXPRESS OR DISCOVER)

H. EXPIRATION DATE

I. AMOUNT OF CHARGE

K. OFFICIAL # OR HIN

J. VESSEL USE/ENDORSEMENT (CHECK ONE)
REC
COM

L. INDICATE SERVICE REQUIRED
Visit our website at http://www.uscg.mil/hq/cg5/nvdc/nvdcfee.asp for complete Fee Schedule
Application Fees (Initial, Exchange, Return, and Replacement) Amount $ ____________
Certificate of Ownership (CG-1330) Fee $125.00
Copy of General Index or Abstract of Title Fee $25.00
Certified Copy of Certificate of Documentation w/Seal Fee $4.00
Deletion Letter $15.00
Bill of Sale $8.00/page
Renewal
Other __________________________ Amount $ ____________

APPLICATION FEES ARE NOT REFUNDABLE (46 CFR 67.500 (e)).
M. REQUESTOR NAME & ADDRESS

N. TELEPHONE NUMBER

O. FAX NUMBER

P. E-MAIL ADDRESS
ATTN:

FOR COAST GUARD USE ONLY
Q. NAME OF PERSON TAKING REQUEST

R. DATE PROCESSED

PRIVACY ACT STATEMENT
IN ACCORDANCE WITH 5 U.S.C. 552(a), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST
GUARD.
1. AUTHORITY: SOLICITATION OF THIS INFORMATION IS AUTHORIZED BY 46 U.S.C., CHAPTERS 121 AND 125; 46 U.S.C. APP. 802 AND 883.
2. THE PRINCIPAL PURPOSE FOR WHICH THIS INFORMATION IS TO BE USED IS TO COLLECT USER FEES DIRECTLY ASSOCIATED WITH THE NATIONAL
VESSEL DOCUMENTATION CENTER FOR WHICH APPLICATION FOR DOCUMENTATION IS MADE.
3. DISCLOSURE OF THE INFORMATION REQUESTED ON THIS FORM IS VOLUNTARY; HOWEVER, FAILURE TO PROVIDE THE INFORMATION REQUESTED WILL
RESULT IN DENIAL OF THE APPLICATION FOR DOCUMENTATION, WHICH MAY PREVENT THE OWNER FROM OPERATING THE VESSEL(S) IN A SPECIFIED
TRADE. 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 FORM IS 5 MINUTES. YOU MAY SUBMIT ANY COMMENTS CONCERNING THE
ACCURACY OF THIS BURDEN ESTIMATE OR MAKE SUGGESTIONS FOR REDUCING THE BURDEN TO: U.S. COAST GUARD, NATIONAL VESSEL
DOCUMENTATION CENTER, 792 T J JACKSON DRIVE, FALLING WATERS, WEST VIRGINIA 25419, OR OFFICE OF MANAGEMENT AND BUDGET, PAPERWORK
REDUCTION PROJECT (1625-0027), WASHINGTON, DC 20503.

CG-7042 (04/12)

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