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U.S. DEPARTMENT OF HOMELAND SECURITY U.S. COAST GUARD CG-6039 (REV. 06/04) Page 1 of 2

Application for CONTINUOUS SYNOPSIS RECORD

OMB APPROVED 1625-0002

I. APPLICATION
1. VESSEL NAME: 2. IMO NUMBER:

3. OFFICIAL NUMBER:

4. DATE OF ORIGINAL DOCUMENTATION:

5. FLAG STATE: United States 7. NAME AND ADDRESS OF CURRENT MANAGING OWNER:

6. HAILING PORT: 8. NAME AND ADDRESS OF CURRENT REGISTERED BAREBOAT CHARTERER(S):

9. NAME AND ADDRESS(ES) OF COMPANY AS DEFINED IN SOLAS REGULATION IX/1

10. CLASSIFICATION SOCIETY(IES):

11. ADMINISTRATION/RECOGNIZED ORGANIZATION THAT ISSUED DOCUMENT OF COMPLIANCE:

12. ADMINISTRATION/RECOGNIZED ORGANIZATION THAT ISSUED ISM CERTIFICATE:

13. ADMINISTRATION/RECOGNIZED ORGANIZATION THAT ISSUED ISS CERTIFICATE:

II. CONSENT AND CERTIFICATION
I CERTIFY THAT I AM LEGALLY AUTHORIZED TO EXECUTE THIS APPLICATION IN THE CAPACITY SHOWN AND THAT THE INFORMATION PROVIDED HEREIN IS COMPLETE AND CORRECT:

___________________________________________________________

___________________________________________________________

SIGNATURE OF AUTHORIZED OFFICER/PERSON
___________________________________________________________

CAPACITY OF AUTHORIZED OFFICER/PERSON
___________________________________________________________

PRINTED NAME OF AUTHORIZED OFFICER/PERSON DATE: _________________________________________

AUTHORIZING COMPANY PHONE: ________________________________________ E-MAIL: ________________________________________
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CG-6039 (REV. 06/04), PAGE 2 OF 2

I. APPLICATION continued:
14. REMARKS:

INSTRUCTIONS

I.

APPLICATION ­ Provide vessel information required for issuing an original Continuous Synopsis Record (CSR). CSR requirements are found in SOLAS 74, Regulation XI-1/5 adopted 12 December 2002. If not applicable, put N/A. 1. Indicate current documented name of the vessel as shown on the Certificate of Documentation. 2. Indicate the IMO number of the vessel. 3. Indicate the official number awarded to the vessel as shown on the Certificate of Documentation. 4. State the original date of documentation of the vessel. 5. Self-explanatory. 6. Indicate the vessel's hailing port. 7. As shown on the Certificate of Documentation. 8. Indicate the name and address(es) of registered bareboat charter(s). 9. Indicate the name and address of the company, which has the responsibility of operating the vessel and has agreed to take on the duties and responsibilities imposed by the International Safety Management Code. Include the address(es) from where it carries out the safety-management activities. 10. Indicate the classification society(ies) with which the vessel is classed. 11. Indicate the Administration or recognized organization that issued the Document of Compliance. 12. Indicate the Administration or recognized organization that issued the Safety Management Certificate. 13. Indicate the Administration or recognized security organization that issued the International Ship Security Certificate. 14. Use this section if additional space is required to complete the other sections. Identify additional information by section number. CONSENT AND CERTIFICATION - Self-explanatory.

II.

THIS IS IN RESPONSE TO AMENDMENTS TO SOLAS REQUIREMENTS TO ENHANCE MARITIME SECURITY. THE CONTINUOUS SYNOPSIS RECORD (CSR) SHALL BE ISSUED BY THE U.S. COAST GUARD UNDER THE AUTHORITY OF THE UNITED STATES. THE CSR CERTIFICATE MUST BE KEPT ON BOARD THE VESSEL AND SHALL BE AVAILABLE FOR INSPECTION AT ALL TIMES.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The Coast Guard estimates that the average burden for this report is 30 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Commandant (G-MOC), U.S. Coast Guard, Washington, DC 20593-0001, or Office of Management and Budget, Paperwork Reduction Project (1625-0002), Washington, DC 20503.

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