Alaska Form 11 525 – Fill Out and Use This PDF

If you are not in substantial compliance with your child support order and are on Alaska's Child Support Services Division's (CSSD) outstanding report, your license is null and void at the time of purchase. You will be subject to criminal sanctions for participation in any commercial crewmember activities. The Department of Fish and Game will match each licensee against CSSD's report. Notice will be served that the license is void and invalid.

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Social Security Number Advisory: You are required to provide your social security number, if over 16 years of age, when applying for a Commercial Crewmember license unless you have an alien registration number. This information is required per AS 25.27.244.

ALASKA RESIDENT AS 16.05.415 & AS 16.05.940: “resident” means, 1) a person (including an alien) who is physically present in Alaska with the intent to remain indeinitely and make a home here, has maintained that person’s domicile in Alaska for the 12 consecutive months immediately preceding this application for a license, and is not claiming residency or obtaining beneits under a claim of residency in another state, territory or country; 2) a member of the military service or U.S. Coast Guard who has been stationed in Alaska for the 12 consecutive months immediately preceding this application for a license; or 3) a dependent of a resident member of the military service or U.S. Coast Guard who has lived in Alaska for the 12 months immediately preced- ing this application for a license. A person who does not otherwise qualify as a resident may not qualify by virtue of an interest in an Alaska business. A person who establishes residency as outlined above remains a resident during an absence for from the state unless during the absence the person (1) establishes or claims residency in another state, territory, or country; or (2) performs an act, or is absent under circumstances, that are inconsistent with the intent to remain indeinitely and make a home in Alaska. A person who establishes residency as outlined above remains a resident during an absence from the state unless during the absence the person (1) establishes or claims residency in another state, territory or country; or (2) performs an act or is absent under circumstances that are inconsistent with the intent to remain indeinitely and make a home in Alaska.

AS 16.05.480(a) A person engaged in commercial ishing is required to hold a limited entry permit, an interim-use permit or a cremember ishing license. If a person already holds a limited entry or interim-use permit for the year, a crewmember license is not needed.

Signature _________________________________________________

AFFIDAVIT FOR DUPLICATE COMMERCIAL FISHING CREWMEMBER LICENSE

I hereby report the loss of my current Commercial Fishing Crewmember License issued to me in accordance with the Fish and Game Code of Alaska as follows:

I have personally reviewed the information on this application and I hereby certify that all the information on this applica- tion is true and correct and that I understand this information except social security number is subject to public disclosure. NOTE: Providing false information is subject to a maximum ine of $10,000 or one year imprisonment or both, per AS

11.56.210 and AS 16.05.665.

Applicant X

Date:

11-525(rev 04/12)