VESSEL
AUTHORIZATION/OPERATOR HISTORY FORM
The
following information will be retained on file by all Agencies on their
Operators authorized to operate a State vessel:
Name:_______________________________
Employed by:_________________________________
Address:_____________________________
(Department, Board, Commission)
_______________________
Zip__________
Assigned to:__________________________________
SSN:_________________________________
(Agency, District, Office)
Operator
License No.:________________
Job Title:_____________________________________
Expiration
Date:_____________________
Immediate Supervisor's Name:___________________
Date
of Birth:_______________________
Operator’s Phone Number:______________________
Issue
Date:__________________________Is the Primary purpose to operate vessels?
Yes___No___
Is
a Current Operator Record attached:____
Has it been verified as accurate?____
Will
this Operator be authorized to operate his or her privately owned vessel in the
course and scope of employment?
Yes____No____
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|
|
TYPE
1 |
TYPE
2 |
TYPE
3 |
TYPE
4 |
TYPE
5 |
TYPE
6 |
|
TYPES
OF VESSELE: |
No
motor, Pirogue skiff Raff
bateau |
Motorboat Class A-1-2-3 |
Airboat Push |
Tug |
Ferry Marsh
Buggy |
Other |
|
State
Vessels Authorized to Operate: |
|
|
|
|
|
|
Date
Trained:______________________________
Source of Training: _____________________
Number
of days per week required to operate a vessel:
_______________
Required
to handle hazardous cargo: Yes____
No____
Trained
to haul/Handle:
Yes____ No____
*************************************************************************************************************************
I
have reviewed this individual's genuine need to operate a State vessel. In conducting this review I have
considered his/her operating experience, class/type equipment to be operated,
and a one year operating record.
The attached Operator Record has been verified as accurate and updated as
necessary. I authorize this
individual to operate the vessels listed above in accordance with the provisions
of this program. This authorization
expires in one year from this date.
_______________________________________
________________________________________
Agency Head Signature
Date of Authorization
(or
specifically designated individual)
DA
2066 (