CG-2633 Application For Waiver and Waiver Order

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
APPLICATION FOR WAIVER AND WAIVER ORDER

OMB. No. 1625-0002
Exp. Date: 06/30/2017

SECTION I - APPLICATION
NAME OF VESSEL

OFFICIAL NUMBER

NAME OF OPERATOR

VESSEL'S EMPLOYMENT

WAIVER REQUESTED

EXTENT TO WHICH WAIVER WILL AFFECT SAFETY OF VESSEL

REASONS JUSTIFYING WAIVER

I HEREBY CERTIFY that in my opinion waiver of compliance with the requirements of law or regulation specified above is necessary in the interest of national
defense.
WAIVER REQUESTED FOR PERIOD
APPLICANT'S TITLE

SIGNATURE

DATE

SECTION II - WAIVER ORDER

(To be filled in by Issuing Officer)
IDENTIFICATION DATA (To be filled only if different from information on application)

PERIOD COVERED BY WAIVER

REQUIREMENTS WAIVER

CONDITIONAL PROVISIONS

THIS IS TO CERTIFY that pursuant to the above application a waiver of the requirements of the navigation and vessel inspection laws administered by the
Coast Guard is hereby made effective to the vessel named above in the interest of National Defense to the extent, for the period, and under the conditions set
forth above.
PLACE

DATE

TITLE OF ISSUING OFFICER

SIGNATURE

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 30 minutes. You may submit any comments concerning the accuracy of this burden
estimate or any suggestions for reducing the burden to: Commandant (CG-CVC-1), U.S. Coast Guard, 2703 Martin Luther King Jr Ave SE, Washington, DC
20593-7501, or Office of Management and Budget, Paperwork Reduction Project (1625-0002), Washington, DC 20503.
Privacy Act Statement
Authority: 33 CFR Part 19.06.
Purpose: The Coast Guard uses this information to review, evaluate, and document requests for the waiving of vessel inspection laws or regulations in the
interest of national defense.
Routine Uses: The information gathered on this form will be used by and disclosed to Coast Guard personnel for evaluating waiver request of inspection
requirements in the interest of national defense. Any external disclosures of data within this record will be made in accordance with DHS/USCG-013, Marine
Information for Safety and Law Enforcement, 74 Federal Register (FR) 30305, June 25, 2009.
Disclosure: Furnishing this information is mandatory for the issuance of national defense waivers per the authority cited above. Failure to furnish the requested
information may delay or prevent the granting of a waiver for the purpose of national defense.
CG- 2633 (05/14)

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