Form CG-4509 US Coast Guard Application For Registration As United St

DEPARTMENT OF HOMELAND SECURITY

OMB APPROVAL NO: 1625-0086

U.S. Coast Guard
Expiration Date: 07/31/2013
APPLICATION FOR REGISTRATION AS UNITED STATES REGISTERED PILOT
INSTRUCTIONS
1. Applicants for selection as Applicant Pilot must submit three letters of reference,
given by persons who have definite knowledge of applicant's qualifications and
fitness for registration as a U.S. Registered Pilot.
2. Applicants for selection as Applicant Pilot must complete service record
documentation in full.
3. Applicants for Original or Renewal Application must attach (paper clip) two full
face photos 1.5" x 2" taken within one year of this application with applicant's
signature in ink across one side of the front.

APPLICANT

4. Mark type of application (applicant, original or renewal).
5. Please type or print.
6. Please sign and scan completed form, and any additional supporting
documentation, to [email protected]. Information may also be sent
via regular mail to: Commandant, U.S. Coast Guard (CG-WWM-2), Attn: Great
Lakes Pilotage, 2100 2nd St SW, Stop 7580, Washington, DC 20593-7580.

ORIGINAL

RENEWAL

APPLICATION IS HEREBY MADE pursuant to the Great Lakes Pilotage Regulations (46 CFR) for registration as a U.S. Registered Pilot for the Great
Lakes as follows: (Specify waters for which application is made, i.e., District No. 1, 2, or 3)

APPLICANT
NAME (Last, first, and middle initial)

MAILING ADDRESS

E-MAIL ADDRESS

PHONE NUMBER

DESCRIPTION OF MERCHANT MARINER CREDENTIAL
DOCUMENT NUMBER

REFERENCE NUMBER

OFFICER ENDORSEMENT, WATERS, AND TONNAGE
PILOTAGE ENDORSEMENTS (Describe in full, attach additional pages if more space is needed)

RADAR OBSERVER UNLIMITED ENDORSEMENT
IF “YES” DATE AND PLACE TRAINING CERTIFICATE ISSUED
YES
NO
SERVICE RECORD (Use additional blank sheets to continue as necessary)
VESSEL

GROSS TONNAGE

WATERS NAVIGATED

POSITION

DATE FROM

DATE TO

CERTIFICATION
ATTENTION: READ THE FOLLOWING PARAGRAPH AND CERTIFICATION CAREFULLY BEFORE SIGNING THIS APPLICATION. A FALSE OR DISHONEST ANSWER
TO ANY QUESTION IN THIS APPLICATION MAY BE GROUNDS FOR RATING YOU INELGIBLE FOR REGISTRATION, AND MAY BE PUNISHABLE BY FINE OR
IMPRISONMENT (Title 18, U.S. Code, Sec. 1001).
CERTIFICATION - I certify that the statements made by me in this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith.
I agree that if registered as a U.S. Registered Pilot, I will obey all applicable regulations of the Secretary of Homeland Security, the U.S. Coast Guard and of any other Federal
Agency; and that I will be continuously available for service when required on those waters of the Great Lakes for which registered.
SIGNATURE OF APPLICANT

DATE

Privacy Act
Authority: 46 U.S.C. §9303 and 46 CFR §401.210.
Purpose: The Coast Guard will use this information to review mariner credentials and qualifications against eligibility requirements for providing registered pilotage on the Great
Lakes.
Routine Uses: Information will be used by Coast Guard personnel to determine an applicant’s suitability to provide registered pilotage service. Any external disclosures of data
within this record will be made in accordance with DHS/USCG-006, Great Lakes Registered Pilot and Applicant Pilot Eligibility System of Records, 73 Fed. Reg. 245 (December
19, 2008).
Disclosure: Furnishing this information is voluntary; however, failure to furnish the requested information may delay or prevent the processing of your application or registration,
which may prevent you from providing registered pilotage service on the Great Lakes.

CG-4509 (12/12)

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