CG-719S (01/14) Small Vessel Sea Service Form

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0040

U.S. Coast Guard

Exp. Date: 01/31/2016

SMALL VESSEL SEA SERVICE FORM
For Service on Vessels Under 200 Gross Tons Only
Section I: Applicant Information (Note: Complete One Form Per Vessel)
Name Last

First

Middle

Vessel Name

Reference Number (if applicable)

Social Security Number

Official Number or State Registration Number

Length
Feet

Vessel Gross Tons

Width (if known)
Feet

Inches

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

Depth (if known)
Feet

Inches

Inches

Served As (Master/Mate/Operator/Deckhand/Engine 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

February
Days

Year

May
Year

Days

Year

June
Days

Year

September
Year

March

Year

Days

Days

Year

Days

Year

November
Days

Year

Days

December
Days

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:

Average distance offshore:

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

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Days

August

Total number of days served on this vessel:

CG-719S (01/14)

Year

July

October
Days

April

Year

Days

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SMALL VESSEL SEA SERVICE FORM
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 credential 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).
Date (MM/DD/YYYY)

Signature of Applicant

x

NOTE:

• 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 credential 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 (MM/DD/YYYY)

Owner's, Operator's, or Master's Name

Owner's, Operator's, or Master's address and phone number

x

Last

Email Address (Optional)

First

Middle

Street Address

City

State

Zip Code

Phone

PRIVACY ACT STATEMENT
Authority: 5 U.S.C. 301; 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7305, 7313, 7314, 7316, 7317, 7319, 7502, 7701, 8701, 8703, 9102; 46 C.F.R. 12.02; 49
C.F.R. 1.45, 1.46
Purpose: The principal purpose for which this information will be used is to determine domestic and international qualifications for the issuance of merchant
mariner credentials. This includes establishing eligibility of a merchant mariner's credential, duplicate credentials, or additional endorsements issued by the
Coast Guard and establishing and maintaining continuous records of the person's documentation transactions.
Routine Uses: The information will be used by authorized Coast Guard personnel with a need to know the information to determine whether an applicant is a
safe and suitable person who is capable of performing the duties of the Merchant Mariner. The information will not be shared outside of DHS except in
accordance with the provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).
Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in non-issuance of
the requested credential.

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 United States 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 (01/14)

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