Passenger Vessel Services Act Compliance Waiver Request Form

Passenger Vessel Services Act Compliance Waiver Request Form
Use this form to request a compliance waiver for passenger vessel services. Provide the vessel, route, service, and request details so the waiver can be reviewed.
Requester & Organization Details
Requester Full Name
First NameMiddle NameLast Name
Title or Role
Organization/Company Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Operator Name
Relationship to Operator
Vessel & Service Information
Vessel Name
Vessel Type / Class
Official Registration or Documentation Identifier
Home Port
Vessel Capacity (Passengers)
Passenger Vessel Service or Route Description
Routing Category
Waiver Request Details
Type of Waiver Requested
Requested Waiver Period Start Date
MonthDayYear
Date
Requested Waiver Period End Date
MonthDayYear
Date
Scope of Relief Sought
Reason for Request and Supporting Circumstances
Operational Impact if Waiver Is Denied; Prior Compliance History or Previous Waiver Requests
Supporting Documentation & Acknowledgment
Supporting Documents
Cancelof
Acknowledgment
Signature
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