ࡱ> BDA 2bjbjVV B-<<"  c!c!c!c!c!w!w!w!8!,!$w!.!!!!!&&&4.6.6.6.6.6.6.$0G3Z.c!)\%&))Z.c!c!!!]o.---)^c!!c!!4.-)4.---!0~Kh7w!D*- ..0.-3+J3-3c!-X&&-'|(&&&Z.Z.L-|&&&.))))3&&&&&&&&&  ) : 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 776.325(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 photocopy of a U.S. Coast Guard physical examination report and signed by an Oregon or Washington licensed physician verifying that the applicant meets the physical, medical and mental criteria required to qualify for a federal pilots license. Submit the completed application with required documentation and $2,682 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. 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