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Commanding Officer |
16W215 83rd Street, Suite D |
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United States Coast Guard |
Burr Ridge, Illinois 60527 |
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Phone: (630) 986-2155 |
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Marine Safety Unit Chicago |
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FAX: (630) 986-2120 |
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WITNESS STATEMENT
WITNESS NAME:__________________________ |
EMPLOYERS NAME:_________________________ |
STREET ADDRESS:________________________ |
EMPLOYER ADDRESS:_______________________ |
CITY/STATE/ZIP:__________________________ |
CITY/STATE/ZIP:____________________________ |
PHONE NUMBER:_________________________ |
PHONE NUMBER:___________________________ |
POSITION:________________________________ |
LICENSE/DOC. #:____________________________ |
I, the undersigned, make the following statement voluntary, without threat, duress or promise of reward:
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I have read my statement as documented above (and if applicable, on continuation pages), and to the best of my knowledge and belief, it is true and correct.
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SIGNATURE |
DATE |