CG-719S Small Vessel Sea Service Form

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
SMALL VESSEL SEA SERVICE FORM

OMB: 1625-0040
Expires: 06/30/12

For Service on Vessels Under 200 Gross Tons Only

SECTION I – APPLICANT INFORMATION (Note: Complete One Form Per Vessel)
Name: Last

First

Middle

Social Security Number

_

Vessel Name

Reference Number

_

Official Number or State Registration Number

Vessel Gross Tons

Length

Width (If known)
ft

in

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

Depth (If known)

ft
in
Served As (Master/Mate/Operator/Deckhand/etc.)

ft

in

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

February

Days

Year

Days

Year

July
Year

March

Days

Year

Days

Year

August

April
Days

Year

September
Days

May
Days

Year

October
Year

Total number of days served on this vessel

Days

June
Days

November
Year

Days

Year

Days

December
Year

Days

Number of days served on Great Lakes
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 hours underway (per day)?
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).

Signature of Applicant

Date

X
NOTE:

If you were not the owner, the Owner, Operator, or Master must complete the remainder of this form.
If you are the owner of the vessel, proof of ownership must be provided.

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

X
Owner’s, Operator’s, or Master’s Name
Last

CG-719S (9/12)

First

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

City

State

Zip Code

Phone
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DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
SMALL VESSEL SEA SERVICE FORM

OMB: 1625-0040
Expires: 06/30/12

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, 11, 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 DOCUMENTS.

“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
comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commanding Officer, U.
S. Coast Guard National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404 or Office of Management and Budget,
Paperwork Reduction Project (1625-0040), Washington, DC 20503.

CG-719S (9/12)

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