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DEPARTMENT OF HOMELAND SECURITY |
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Print |
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U.S. Coast Guard |
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CERTIFICATE OF DISCHARGE TO MERCHANT MARINER |
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Signature of Mariner |
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Date of Shipment Month/Day/Year (Example: 01/20/2012) |
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Name of Mariner (Print in Full, Last, First, and Middle Initial) |
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Place of Shipment (Port or City, State or Country) |
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Citizenship |
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Credential No. |
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Date of Discharge Month/Day/Year (Example: 01/20/2012) |
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Or |
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Reference No. |
_____________________ |
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Rating (Capacity in Which Employed) |
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Place of Discharge (Port or City, State or Country) |
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Nature of Voyage |
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Foreign |
Intercoastal |
Coastwise |
Name of Operating Company |
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(Check only one box) |
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Other: ____________________________ |
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I HEREBY CERTIFY that the above entries were made by me and are |
Name of Ship |
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correct and that the signatures hereto were witnessed by me. |
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Dated: ________________________ |
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Official No. |
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Horsepower |
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Month/Day/Year (Example: 01/20/2012) |
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Class of Vessel |
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______________________________________________________ |
Tank |
Freight |
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Other: _______________________________________________ |
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Signature of Master |
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Mode of Propulsion |
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Ｐｄｖｗｈｕﾶｖ＃Ｕｈｉｈｕｈｑｆｈ＃Ｑｒ１＃ｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂｂ＃ |
Motor |
Gas Turbine |
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Steam |
Other: __________________________________ |
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NOTE ﾱ＃This form is required by law (46 USC 10311). Failure to submit |
Tonnage |
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GRT |
OR |
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ITC |
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can result in a civil penalty of $5,000 as prescribed by 46 USC 10321. |
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INSTRUCTIONS
The vessel master or individual in charge shall prepare the CG-718A. A Certificate of Discharge and two copies should be printed out.
All three copies of the form MUST be signed in ink by the vessel master and the discharged mariner. Distribute the Certificates of Discharge as follows:
1 - One copy shall be given to the discharged mariner.
2 - One copy shall be mailed in accordance with Title 46 Code of Federal Regulation Part 14, Subpart C, by the operating company to the following address:
Commanding Officer United States Coast Guard National Maritime Center (NMC-41) 100 Forbes Drive
Martinsburg, WV 25404
3 - One copy shall be maintained by the operating company for a period of three years from date of issuance.
PRIVACY ACT STATEMENT
In accordance with 5 U.S.C. § 552a(e)(3), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO THE U.S. COAST GUARD.
1.AUTHORITY WHICH AUTHORIZED THE SOLICITATION OF INFORMATION:
A.46 U.S.C. § 10311
B.SEE 46 CFR PART 14.
2.PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED:
A.TO ESTABLISH ELIGIBILITY FOR A MERCHANT MARINER'S CREDENTIAL, DUPLICATE CREDENTIAL, OR ADDITIONAL ENDORSEMENTS ISSUED BY THE U.S. COAST GUARD.
B.TO ESTABLISH AND MAINTAIN A RECORD OF THE PERSONS SEA SERVICE.
C.PART OF THE INFORMATION IS TRANSFERRED TO A FILE MANAGEMENT COMPUTER SYSTEM FOR A PERMANENT RECORD.
3.THE ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION:
A.TO MAINTAIN RECORDS REQUIRED BY 46 U.S.C. 7319 AND 7502.
B.TO ENABLE ELIGIBLE PARTIES (i.e. the mariner's heirs or properly designated representative) TO OBTAIN INFORMATION.
C.TO PROVIDE INFORMATION TO THE U.S. MARITIME ADMINISTRATION FOR USE IN DEVELOPING MANPOWER STUDIES AND TRAINING BUDGET NEEDS.
D.TO DEVELOP INFORMATION AT THE REQUEST OF COMMITTEES OF CONGRESS.
E.TO PROVIDE INFORMATION TO LAW ENFORCEMENT AGENCIES FOR CRIMINAL OR CIVIL LAW ENFORCEMENT PURPOSES.
F.TO ASSIST U.S. COAST GUARD INVESTIGATING OFFICERS AND ADMINISTRATIVE LAW JUDGES IN DETERMINING MISCONDUCT, CAUSES OF CASUALTIES, AND APPROPRIATE SUSPENSION AND REVOCATION ACTIONS.
4.WHETHER OR NOT DISCLOSURE OF SUCH INFORMATION IS MANDATORY OR VOLUNTARY (REQUIRED BY LAW OR OPTIONAL) AND THE EFFECTS ON THE INDIVIDUAL, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION: DISCLOSURE OF THIS INFORMATION IS VOLUNTARY, BUT SUBJECT MARINERS MAY NOT BE PERMITTED TO ENGAGE IN EMPLOYMENT ABOARD THE VESSEL FOR WHICH CERTIFICATES OF DISCHARGE ARE REQUIRED.
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 2 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to the National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404, or Office of Management and Budget, Paperwork Reduction Project (1625-0012), Washington, DC 20503.
CG-718A (05/12) |
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