ࡱ> BDAq`  bjbjqPqP <-::8$$.LLLLL@'B'B'B';}'*-$/h22-"]""-LL-&&&"jLL@'&"@'&&&L@ ` #&&l-0.&2#J2&2&H &C m--.&^.""""$ Oregon Board of Maritime Pilots APPLICATION FOR ORIGINAL PILOT LICENSE Oregon Revised Statute 776.115 856-010-0010 In addition to the qualifications required for licensing of pilots under ORS 776, the applicant shall: (1) Present an application in writing to the administrator of the board on the form provided by the board for the pilotage ground for which the applicant intends to become licensed. The application shall be filed not less than 30 days prior to appearance before the board for a written examination and may be supplemented at any time until the examination is taken. The board shall consider the application and upon approval, the written examination will be scheduled. The examination shall be proctored by the boards administrator. The examination for each pilotage ground shall be prepared by the board with the assistance of the boards licensed training organization for that pilotage ground. The examination will test for skill and knowledge of those factors identified in ORS 776.035(2) and ORS 776.326(1)(b). The examination will be graded by the board member from the pilotage ground for which the applicant is seeking a license. If requested by the training course monitor, up to two additional pilots selected by the training course monitor and approved by the board may participate with the board member in grading the exam. The examination will be pass/fail. (2) Accompany the application with a physical examination form provided by the board and signed by an Oregon licensed physician verifying that the applicant meets the physical and mental criteria in subsections (a) through and including (l). Submit the completed application with required documentation and $2,500 license fee to the Oregon Board of Maritime Pilots, State Office Building Suite 507, 800 NE Oregon St. # 15, Portland, Oregon 97232. Telephone: 971/673-1530 Fax: 971/673-1531. Consistent with ORS 25.785, ORS 305.385, 42 USC 405(c)(2)(c)(I) and 42 USC 666(a)(13), as part of your application for an original license, you are required to provide your Social Security Number. Failure to provide your Social Security Number will be a basis to refuse to issue or renew the license you seek. This record will be used for child support enforcement and tax administration purposes only. Although a number other than your Social Security Number appears on the face of the license, your Social Security Number will remain on file with the agency.  Date Pilotage Ground Desired Name Address Telephone Social Security No. Birth Date Place US Citizen? Naturalization Cert. No. Date Place Any physical defects or limitations? Any serious illnesses in last two years? If so, list: Have you ever been rejected by a Life Insurance Co.?  Applicant for Columbia River Bar Pilotage Ground (ORS 776.325) Means available to you for boarding and leaving vessels that you will pilot: Supply a record of at least 100 crossings of the bar, with at least 25% of the crossings made during the hours of darkness. Include documentation of at least 10 ship dockings and undockings.  Applicant for Columbia & Willamette River Pilotage Ground (ORS 776.325) Supply a record of at least 270 days of continuous experience piloting ocean-going vessels in the domestic trade over the pilotage ground for which you are making application, including the necessary experience in handling ocean-going vessels through the bridges, under varying conditions, with and without towboats.  Applicant for Coos Bay or Yaquina Bay Bar Pilotage Grounds (ORS 776.325) Means available to you for boarding and leaving vessels that you will pilot: Supply a record of at least 100 crossing of the CoosBay/Yaquina Bay bars with at least 25 crossings at night; 25 dockings and undockings; and 25 trips through each of the bridges.  By my signature, I hereby affirm that I have read and will comply with ORS Chapter 776, and the rules adopted by the Oregon Board of Maritime Pilots pertaining to pilots and pilotage. Signature Date    !Hght  I ( x kCFGJKOUXY\]abܷu_*jh Lh@CJOJQJUmHnHuh@@CJOJQJh`:A@CJOJQJh4@CJOJQJh`:ACJOJQJh$qCJOJQJh4CJOJQJh45CJOJQJh456@OJQJh45@CJ$OJQJh4@OJQJh4@CJOJQJh45@CJOJQJ% !Hgh $ 0l*$a$$ lp@ `'*$a$ $ `'*$a$$ p`'*$a$ $ 0d*$a$ $ 0*$a$gd@ $ 0*$a$ $ *$a$     &12345MPUX^_`ab贩h4@OJQJh Lh>*@OJQJh4>*@OJQJh Eh4@CJOJQJh Lh>*@CJOJQJh4>*@CJOJQJh4@CJOJQJh4@CJOJQJ>45ab?@PR:$ 0l`'*$a$$*$a$ $ `'*$a$$ 0l*$a$$ @ P`'*$a$$ 0l*$a$gdg$  p@ P`'*$a$?@PQ#$pqrsǻyj]P]h46@CJOJQJh`:A6@CJOJQJh Lhh4@CJOJQJ h`:ACJ h4CJ)jh Lh5@OJQJUmHnHu h46CJhD>*@CJOJQJh4>*@CJOJQJh4@CJOJQJh Lhh45@CJOJQJh45@OJQJh4@OJQJ&jh Lh@OJQJUmHnHu#$s'(*d $ *$a$;$ 0l`'*$a$$ 0l*$a$9$*$a$&'()*  ÿyogcgcoh1/jh1/Uh4@OJQJhD>*@CJOJQJh4>*@CJOJQJh4@CJOJQJ&jh4CJOJQJUmHnHuh4@CJOJQJh4 h4CJjh LhCJUmHnHuh4@CJOJQJh46@CJOJQJh Lh6@CJOJQJ   $ *$a$:....()()))()00P8$:p LhBP/ =!"#$% <H@H Normal CJOJQJ_HkHmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List ,O, Document 86O6 Document 4 56CJ,O, Document 6,O!, Document 5HO1H Document 2CJOJQJkHmH sH u,OA, Document 7.OQ. BibliogrphytObt Right Par 1# 0P*$^`P CJOJQJ_HkHmH sH tH vOrv Right Par 2& 0P*$^`P CJOJQJ_HkHmH sH tH HOH Document 3CJOJQJkHmH sH uzOz Right Par 3) 0ppP*$^p`P CJOJQJ_HkHmH sH tH |O| Right Par 4, 0p@ @ P*$^@ `P CJOJQJ_HkHmH sH tH O Right Par 5/ 0p@ *$^` CJOJQJ_HkHmH sH tH O Right Par 62 0p@ *$^` CJOJQJ_HkHmH sH tH O Right Par 75  0p@ P*$^`P CJOJQJ_HkHmH sH tH O Right Par 88 0p@ P*$^`P CJOJQJ_HkHmH sH tH bOb Document 1$$*$ 0 CJOJQJ_HkHmH sH tH (O( Doc InitFOF Tech InitCJOJQJkHmH sH ujO"j Technical 5" 0*$`#5CJOJQJ_HkHmH sH tH jO2j Technical 6# 0*$`#5CJOJQJ_HkHmH sH tH JOAJ Technical 2CJOJQJkHmH sH uJOQJ Technical 3CJOJQJkHmH sH ubObb Technical 4 &*$ 0#5CJOJQJ_HkHmH sH tH JOqJ Technical 1CJOJQJkHmH sH ujOj Technical 7( 0*$`#5CJOJQJ_HkHmH sH tH jOj Technical 8) 0*$`#5CJOJQJ_HkHmH sH tH ^O^ Pleading*d*$ 0 CJOJQJ_HkHmH sH tH P@P TOC 1,+ (#$0*$]^`0L@L TOC 2(, (#$0*$]^`0L@L TOC 3(- (#$p0*$]^p`0L@L TOC 4(. (#$@ 0*$]^@ `0L@L TOC 5(/ (#$0*$]^`0D@D TOC 6 0 (#$0*$^`0:@: TOC 710*$^`0D@D TOC 8 2 (#$0*$^`0D@D TOC 9 3 (#$0*$^`0P @P Index 1(4 (#$`*$]^``P @P Index 2(5 (#$0*$]^`00Ob0 toa6*$ (#$*"@* Caption7:O: _Equation Caption\B@\ Body Text9$ 0l*$a$6@CJOJQJ\P@\ Body Text 2:$ 0l`'*$a$ @OJQJbQ@b Body Text 3;$ 0l*$a$56@CJOJQJ , !Hgh  4 5 a b ? @ P R #$s'(* 0@0@0@0@000@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0@0:0@0@0090@0@0@0@00@0@;0@;0@00@0I00@0I00@0I00@0I00@0I00I00l     8@f(  bB  c $8c?"TB   c $8c?TB   c $8c?TB   c $8c?TB   c $8c?TB  c $8c?B S  ? P ( 9f*:t bf*ct f*t f*t f*t*twWܰb?wW4z`@wW4`AwW`BwWtCwWdaDwWaEwWTu`FwW *urn:schemas-microsoft-com:office:smarttags PostalCode8 *urn:schemas-microsoft-com:office:smarttagsCity; *urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsState9*urn:schemas-microsoft-com:office:smarttagsplace ,        5 M b   333333333IxCFGJKOUXY\]ab 2 3 _ ` P Q qrs&''()    @`:ADd Lh$q1/I EDg4D r y_0@HP LaserJet Series IILPT1:winspoolHP LaserJet Series IIHP LaserJet Series II4C od,,LetterDINU"4'ZHP LaserJet Series II4C od,,LetterDINU"4'Zssss P@UnknownGz Times New Roman5Symbol3& z ArialUCG Times 12ptRockwella CG Times 8ptTimes New Roman?5 z Courier New 9)4 7 vfb b Y)4d2Q)KX ?1/2Oregon Board of Maritime PilotsBoard of Maritime PilotsBoard of Maritime PilotsOh+'0  DP p |   Oregon Board of Maritime PilotsBoard of Maritime PilotsOriginal Application.dotBoard of Maritime Pilots1Microsoft Office Word@Ik@'@4@~b ՜.+,0 hp  State of Oregon  Oregon Board of Maritime Pilots Title  !"#$%&'()*+,-./02345678:;<=>?@CRoot Entry F`i$E1Table2WordDocument<-SummaryInformation(1DocumentSummaryInformation89CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q