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
STATEMENT OF EXPERIENCE FOR BOAT OPERATION
Vessel Name and Official Numbers
* Vessel Class
# 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?
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.
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