PRIVACY ACT STATEMENT
1. Authority: 14USC 826 end 827.
2. Principal Purpose: To provide a means of selection and acceptance of
vessels as U.S. Coast Guard operational and non-operational facilities.
3. Routine Uses: Retained by directors of Auxiliary and cognizant USCG group
commanders as a record of which vessels have been accepted by the
director as U.S. Coast Guard operational and non-operational facilities.
4. Disclosure: Voluntary, however, the detailed information requested on
this form enables the coast Guard to select qualified vessels as Coast
Guard facilities. Failure by the member to provide all or part of the
information will prevent the acceptance of the vessel as a Coast Guard facility.
Make sure your letters and numbers are printed like this:
1234567890ABCDEFGHIJKLMNOPQRSTUVWXYZ
VESSEL FACILITY INSPECTION AND OFFER FOR USE FORM
This form is used to report a vessel facility inspection and offer for use as
well as to report changes it the status of a facility. If you sell or trade
your facility and acquire a new one, this form is used to remove the old
facility and enter the new one into the data base.
INSTRUCTIONS (Use Ballpoint pen )
Check the appropriate box, in the heading, for the type of report - initial
(new) report, minspection (reoffer), or change.
SECTION I - OWNER DATA Shaded area in SECTION I is for Director use only
OWNER'S MEMBER NUMBER - The member holding the largest percentage of
ownership enters their member number.
If this owner is not Auxiliary, then enter "NON AUX." If the facility has multiple
owners, enter primary owner's member number. If the facility has multiple owners end is
being offered for use, then attach "Assent end Authorization for Use" information
outlined in the Auxiliary Operations Policy Manual. If the facility is corporate owned,
leave member number blank. If the facility is corporate owned and being offered for use,
then also attach the required information and the "Corporate Resolution" authorizing
offer for use as outlined in the Auxiliary Operations Policy Manual.
OWNER'S LAST NAME - Enter the last name, first name, end middle initial
that corresponds to the member number. If the facility is corporate owned,
enter the corporation's name.
TYPE OF OWNERSHIP - Check the appropriate box for ownership of facility.
CO-OWNER'S MEMBER NUMBER AND LAST NAME - Complete as above instructions for "OWNER,"
except this applies to the owner who holds the second largest percentage of owrtership.
REG. or DOC. NUMBER - Enter the facility's state registration number or documentation
number. Do not use hyphens or leave spaces between letters end numerals. Example: MD
9185 N is entered as MD9185N or CA 625 BA is entered as CA625BA. Leave unused blocks
blank. If number exceeds available spaces enter as many as possible.
FACILITY'S NAME - Enter the nameof the vessel. If the vessel does not have a
name, leave this box blank.
FACILITY'S DISTRICT CALL SIGN - Enter the district assigned CALL SIGN for the
facility being inspected.
PREVIOUS BOAT NO. - As necessary, enter Ihe previous vessel's registration
number if the facility being inspected replaces one that you previously
owned. Do not use hyphens or leave spaces between letters and numerals.
SECTION II - FACILITY DATA (NOTE: To be completed by owner before inspection of vessel.)
VESSEL LOCATION - Enter the city and state where the vessel is located or berthed.
ZIP CODE - Enter zip code where the vessel is located or berthed.
TRAILERED - Check appropriate box.
MANUFACTURER - Enter the name of the manufacturer of the vessel.
MODEL - Enter the manufacturer's model number or the model name of the vessel.
YEAR - Enter the year the vessel was built.
LENGTH - State the length of the hull in feet, (as indicated on the
Registration/Documentation papers).
BEAM - State beam of vessel in feet.
DRAFT - State the draft of vessel in feet.
TYPE VESSEL - State if vessel is OPEN or CLOSED construction, style of vessel,
(example sailboat, cruiser, trawler, etc).
NO. BUNKS - Indicate sleeping capacity.
INSTALLED HEAD - Check appropriate box.
RANGE INSTALLED - Check appropriate box.
SPACE HEATER - Check appropriate box.
WATER CAPACITY - Enter the water tank capacity in gallons. If no water tank
installed, indicate "Not Applicable" or NA.
TYPE POWER - Indicate type of power, (example: outboard, auxiliary sail,
inboard, I/O or sailboat).
NO. ENGINES - Indicate the number of main propulsion engines on the vessel.
ENGINE MANUFACTURER - Indicate the name of the engine(s) manufacturer.
(Continued on the reverse)
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