National Maritime Center
Providing Credentials to Mariners
11/29/2018 Page | 1
Correspondence Request
Mariner Information:
Name
1
:
Date of Birth:
Reference
Number:
Are you a U.S. citizen
2
?:
Address: City: State: Zip Code:
Company
Name:
Mariner Signature
3
:
Requester Information:
Name:
Phone:
1
Name of individual who is the subject of the record sought. First name and last name are mandatory.
2
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.
3
Signature of individual who is the subject of the record sought.
Requester Signature:
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:
E-mail:
Request Type: (Select all that apply.)
*If you selected Specific Document from Record, select all
document types that apply:
Date:
Date:
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.)
MCP-FM-NMC4-84 (05)
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:
Form DD214/Benefits
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
LAST:
FIRST:
The Request Type is not listed. (Please specify your request):
