CG-6039 Application for Continuous Synopsis Record

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
APPLICATION FOR CONTINUOUS SYNOPSIS RECORD

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

SECTION I - APPLICATION
1. VESSEL NAME

2. IMO NUMBER

3. OFFICIAL NUMBER

4. DATE OF ORIGINAL DOCUMENTATION

5. FLAG STATE

6. HAILING PORT

UNITED STATES

7. NAME AND ADDRESS OF CURRENT MANAGING OWNER

8. NAME AND ADDRESS OF CURRENT REGISTERD BAREBOAT
CHARTERER(S)

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

10. CLASSIFICATION SOCIETY(IES)
11. ADMINISTRATION/RECOGNIZED ORGANIZATION THAT ISSUED
DOCUMENT OF COMPLIANCE

12. ADMINISTRATION/RECOGNIZED ORGANIZATION THAT ISSUED ISM
CERTIFICATE

13. ADMINISTRATION/RECONGIZED ORGANIZATION THAT ISSUED ISS
CERTIFICATE

SECTION 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

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 AUTHOIRTY OF
THE UNITED STATES. THE CSR CERTIFICATE MUST BE KEPT ON BOARD THE VESSEL AND SHALL BE AVAILABLE
FOR INSPECTION AT ALL TIMES.

Privacy Act Notice
Authority: 33 Code of Federal Regulations (CFR) §§ 101.115(b), and 104.297(a) authorizes the collection of this information.
Purpose: The Coast Guard uses this information to review and validate the particulars of the vessel for the intended purpose of issuing a Continuous Synopsis
Record.
Routine Uses: The information will be used by and disclosed to Coast Guard personnel for the issuance of a Continuous Synopsis Record. Additionally, the
Coast Guard may disclose applicable information on this form under the Freedom of Information Act (FOIA) via a written FOIA request.
Disclosure: Furnishing this information is voluntary. However, failure to furnish the requested information may delay or prevent the issuance of a Continuous
Synopsis Record. Personal privacy information will not be disclosed.
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.
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SECTION I - APPLICATION continued
14. REMARKS

INSTRUCTIONS
I. 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 name and address(es) of registered bareboat charter(s).
9. 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.
10. Indicate the classification society(ies) with which the vessel is classed.
11. Indicate the Administration or recognized organization that issued the Document of Compliance.
12. Indicate the Administration or recognized organization that issued the Safety Management Certificate.
13. Indicate the Administration or recognized security organization that issued the International Ship Security Certificate.
14. Use this section if additional space is required to complete the other sections. Identify additional information by section
number.
II. CONSENT AND CERTIFICATION - Self-explanatory.
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