Hunter MH37 - Page 37

Documents and Forms
For each question below, please provide answers IF APPLICABLE AND IF KNOWN, otherwise leave blank.
YOUR BOAT OPERATOR
NAME/ADDRESS
First Name
MI
Last Name
Street
City
State
Zip
AGE/GENDER/PHONE
Date of Birth
PPGG\\\\
Age
Gender
Male
Female
Phone
YOUR BOAT OWNER
If same as \RXUboat RSHUDWRUSKIP rest of YOUR BOAT OWNER section.
NAME/ADDRESS/PHONE
First Name
MI
Last Name
Street
City
State
Zip
Phone
PERSON SUBMITTING THIS REPORT
If same as
\RXUboat RSHUDWRUOR RZQHU, SKIP rest of PERSON SUBMITTING THIS REPORT section.
NAME/ADDRESS/PHONE/ROLE
First Name
MI
Last Name
Street
City
State
Zip
Phone
I was a(n) VHOHFWRQH
Other person on board
WKLVboat
Accident witness
QRWon board WKLVboat
Other GHVFULEH
SIGNATURE OF PERSON SUBMITTING THIS REPORT
Your signature
Date PPGG\\\\
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.
CG-3865 (1/11) Page 6 of 6
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