Form CG-6039 Application for Continuous Synopsis Record

U.S. DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-6039 (REV. 04-09)
Page 1 of 2

Application for
CONTINUOUS SYNOPSIS RECORD

OMB APPROVED
1625-0002
Expiration Date:

I. APPLICATION
1. VESSEL NAME:

2. IMO NUMBER:

3. OFFICIAL NUMBER:

4. DATE OF ORIGINAL DOCUMENTATION:

5. FLAG STATE: UNITED STATES

6. HAILING PORT:

7. NAME AND ADDRESS OF CURRENT
MANAGING OWNER:

8. REGISTERED OWNER IDENTIFICATION NUMBER:
9. NAME AND ADDRESS OF CURRENT REGISTERED
BAREBOAT CHARTERER(S):

10. NAME AND ADDRESS(ES) OF COMPANY
AS DEFINED IN SOLAS REGULATION IX/1:

11. COMPANY IDENTIFICATION NUMBER:

12. CLASSIFICATION SOCIETY(IES):

13. ADMINISTRATION/RECOGNIZED ORGANIZATION
THAT ISSUED DOCUMENT OF COMPLIANCE:

14. ADMINISTRATION/RECOGNIZED ORGANIZATION
THAT ISSUED ISM CERTIFICATE:

15. ADMINISTRATION/RECOGNIZED ORGANIZATION
THAT ISSUED ISS CERTIFICATE:

II. CONSENT AND CERTIFICATION
I CERTIFY THAT I AM LEGALLY AUTHORIZED TO EXECUTE THIS APPLICATION IN THE CAPACITY SHOWN AND
THAT THE INFORMATION PROVIDED HEREIN IS COMPLETE AND CORRECT:
___________________________________________________________

SIGNATURE OF AUTHORIZED OFFICER/PERSON

___________________________________________________________

CAPACITY OF AUTHORIZED OFFICER/PERSON

___________________________________________________________

___________________________________________________________

PRINTED NAME OF AUTHORIZED OFFICER/PERSON

AUTHORIZING COMPANY

DATE:_________________________________________

PHONE:________________________________________
E-MAIL: ________________________________________
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CG-6039 (REV. 04-09), PAGE 2 OF 2

I. APPLICATION continued:
16. REMARKS:

INSTRUCTIONS

I.

II.

APPLICATION – Provide vessel information required for issuing an original Continuous Synopsis Record (CSR).
CSR requirements are found in SOLAS 74, Regulation XI-1/5 adopted 12 December 2002.
1. Indicate current documented name of the vessel as shown on the Certificate of Documentation.
2. Indicate the IMO number of the vessel.
3. Indicate the official number awarded to the vessel as shown on the Certificate of Documentation.
4. State the original date of documentation of the vessel.
5. Self-explanatory.
6. Indicate the vessel’s hailing port.
7. As shown on the Certificate of Documentation.
8. Indicate the Registered Owner Identification Number.
9. Indicate the name and address(es) of registered bareboat charter(s).
10. Indicate the name and address of the company, which has the responsibility of operating the vessel and has agreed
to take on the duties and responsibilities imposed by the International Safety Management Code. Include the
address(es) from where it carries out the safety-management activities.
11. Indicate the Company Identification Number.
12. Indicate the classification society(ies) with which the vessel is classed.
13. Indicate the Administration or recognized organization that issued the Document of Compliance.
14. Indicate the Administration or recognized organization that issued the Safety Management Certificate.
15. Indicate the Administration or recognized security organization that issued the International Ship Security Certificate.
16. Use this section if additional space is required to complete the other sections. Identify additional information by
section number.
CONSENT AND CERTIFICATION - Self-explanatory.

THIS IS IN RESPONSE TO AMENDMENTS TO SOLAS REQUIREMENTS TO ENHANCE MARITIME SECURITY. THE
CONTINUOUS SYNOPSIS RECORD (CSR) SHALL BE ISSUED BY THE U.S. COAST GUARD UNDER THE AUTHORITY
OF THE UNITED STATES. THE CSR CERTIFICATE MUST BE KEPT ON BOARD THE VESSEL AND SHALL BE
AVAILABLE FOR INSPECTION AT ALL TIMES.
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.

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