National Maritime Center
Providing Credentials to Mariners
11/29/2018 Page | 1
Date of Birth:
Are you a U.S. citizen
Address: City: State: Zip Code:
Name of individual who is the subject of the record sought. First name and last name are mandatory.
Individual submitting a request under the Privacy Act of 1974 must be either "a citizen of the United States or an Alien lawfully admitted for permanent
residence," pursuant to 5 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C. 552, rather than
Privacy Act requests, for individuals who are not United States citizens or aliens lawfully admitted for permanent residence.
Signature of individual who is the subject of the record sought.
OPTIONAL: Authorization to Release Information to Another Person
This form is also to be completed by a requester who is authorizing information relating to himself or herself to be released to another person.
Further, pursuant to 5 U.S.C. Section 552a(b), I authorize the U.S. Department of Homeland Security to release any and all information relating
to me to:
Request Type: (Select all that apply.)
*If you selected Specific Document from Record, select all
document types that apply:
By signing and submitting this request, I declare under penalty of perjury under the laws of the United States of America that the foregoing is
true and correct, and that I am the person named above, and I understand that any falsification of this statement is punishable under the
provisions of U.S.C. Section 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years or both, and that requesting
or obtaining any record(s) under false pretenses is punishable under the provisions of 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.
If requester is submitting on behalf of a deceased mariner, proof of death is required. (E.g., death certificate, obituary, etc.)
Please follow the instructions below so we may process your request:
STEP 1 - Complete all appropriate fields in this request.
STEP 2 - Print request by clicking the Print button on the bottom of this page. Manually sign the
appropriate signature fields.
STEP 3 - Scan the signed request. Send signed request and any supporting documentation to
the National Maritime Center (NMC) at OSC-SMB-NMC-4-Correspondence@uscg.mil.
FIRST: MIDDLE: LAST: SUFFIX:
Subpoenas/Affidavits/Notice of Deposition (Touhy)
Copy of Entire Record
Specific Document from Record (see next section)*
Copy of Medical Documents/Physical Forms
Copy of CDs
Copy of Training Certificate(s)
Copy of Towing Officers' Assessment Record (TOAR)
Copy of Sea Service
Certified Copy of Record
The Request Type is not listed. (Please specify your request):