CG-719S 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 (OPTIONAL CG-719S)
For Service on Vessels of Less Than 200 Gross Register 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(s) listed on the registration, certificate, or document

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:

Reset

Days

August

Total number of days served on this vessel:

CG-719S (04/17)

Year

July

October
Days

April

Year

Days

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SMALL VESSEL SEA SERVICE FORM (OPTIONAL CG-719S)
Section III: Signature and Verification - Applicant Read Before Signing!
• Owners of vessels may attest to their own experience and provide proof of ownership per 46 CFR 10.232.
• Those who do not own their own vessel must obtain letters or other evidence from licensed personnel or the owners of the vessels listed per 46 CFR 10.232.
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

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).
Date (MM/DD/YYYY)

Signature and Title of Person Attesting to Experience

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

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

Email Address (Optional)

First

Middle

Street Address

City

State

Zip Code

Phone

PRIVACY NOTICE
Authority: 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7502, 46 C.F.R. 10.301
Purpose: The information is collected by the Coast Guard to determine whether an applicant meets the regulatory standards for issuance of
a U.S. Merchant Mariner Credential (MMC). The Coast Guard evaluates an applicant's qualifications to determine compliance with the
national and international requirements for issuance of the MMC, any endorsement within the MMC, and medical certificate.
Routine Uses: The information is used by authorized Coast Guard personnel who have a need for the record to determine whether an
applicant is a safe and suitable person and qualifies for the MMC, any endorsement within the MMC, and medical certificate. In addition, the
Coast Guard uses this information to maintain and update records of merchant mariner documentation transactions. 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
the non-issuance of the MMC, any endorsement within the MMC, and medical certificate.

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: Chief, Office of Merchant Mariner Credentialing, 2703 Martin Luther King, Jr. Ave, S.E., STOP
7509, Washington, D.C., 20593-7509 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.
CG-719S (04/17)

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