Free F416-034-000 app state of WA charter boat operator license - Washington

Department of Labor and Industries WISHA Services Division PO Box 44655 Olympia WA 98504-4655

APPLICATION FOR STATE OF WASHINGTON
CHARTER BOAT OPERATORS LICENSE
Phone number Date of birth

Name of applicant Mailing address City Body of water operating on

State

ZIP+4

STATEMENT OF EXPERIENCE FOR BOAT OPERATION
Vessel Name and Official Numbers

* Vessel Class

Tonnage

# Hours of Operation

* Vessel Class Less than 16 ft ­ Class A

16 ft to 26 ft ­ Class 1

26 ft to 40 ft ­ Class 2

40 ft to 65 ft ­ Class 3

Have you ever held a United States license as master, mate, pilot or engineer of vessels?

Yes

No

If yes, state the kind of license last held, when issued, what title did you hold, and the port where issued. Was the last license held by you suspended or revoked? If suspended or revoked, state "suspended" or "revoked", when suspended or revoked, the port where the inspectors who acted on the license were located, and the cause.

Yes

No

We, the undersigned, do certify from personal knowledge that the applicant named _________________________________________, is a person of temperate habits and good character, and recommend him/her as a suitable person to be entrusted with the duties of the station for which he/she makes application Name (print & sign) Address & Phone number Occupation

ATTACH COMPLETED PHYSICAL EXAMINATION WITH COLOR VISION.

F416-034-000 application for charter boat operators license 7-05