Hunter e33 Operator's Manual page 33

For each question below, please provide answers
YOUR BOAT OPERATOR
NAME/ADDRESS
First:
Street:
City:
AGE/GENDER/PHONE
Age: Gender:
YOUR BOAT OWNER
If same as your boat operator SKIP rest of YOUR BOAT OWNER section.
NAME/ADDRESS/PHONE
First:
Street:
City:
Phone: -
PERSON SUBMITTING THIS REPORT
If same as your boat operator OR owner , SKIP rest of PERSON SUBMITTING THIS REPORT section.
NAME/ADDRESS/PHONE/ROLE
First:
Street:
City:
Phone: -
I was a(n) (select one):
Other person on board this boat
Accident witness not on board this boat
Other (describe):
SIGNATURE OF PERSON SUBMITTING THIS REPORT
Your signature:
An Agency may not conduct or sponsor and a person is not required to respond to an information collection, unless it displays a currently valid OMB Control Number.
The Coast Guard estimates that the average burden for this report form is 30 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to:
Commandant (CG-5422), U.S. Coast Guard, Washington, DC 20593-0001 or Office of Management and Budget, Paperwork Reduction Project (1625-0003), Washington, DC 20503.
U.S. Dept. of Homeland Security
IF APPLICABLE AND IF KNOWN
MI:
Male Female
MI:
-
MI:
-
U.S. Coast Guard CG-3865 (Rev 07-08)
Last:
State:
Phone:
Last:
State:
Last:
State:
Date:
, otherwise leave blank.
Zip:
- -
Zip:
Zip:
-
-
-
mm/dd/yy
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