Application for Commercial Instructor / Operator Permit - Hawaii

This "Application for Commercial Instructor / Operator Permit" is a document issued by the Hawaii Department of Land & Natural Resources specifically for Hawaii residents with its latest version released on July 1, 2011.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Hawaii Department of Land & Natural Resources.

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APPLICATION FOR
COMMERCIAL INSTRUCTOR / OPERATOR PERMIT
Division of Boating and Ocean Recreation
Department of Land and Natural Resources, State of Hawai'i
PERMIT INFORMATION
Application type (
) :
New
Renewal
one
q
q
4
Instructor Type:
q
Surfboard Instructor
q
Canoe Captain
q Thrill Craft Instructor
q
Sailboard Instructor
q
Canoe 2nd Captain
q
Kayak Instructor
Attach
Dive Instructor
q Canoe Learner Steersmam
q
Photo
Operator Type:
Sail Operator (indicate hull type):
Mono-hull
Multi-hull
q
m
m
q
Motorboat Operator:
m
Parasail
m
Shuttle
m
Excursion
m
Dive
Other:
m
Indicate the Ocean Recreation Managment Area
of the ocean waters in the State of Hawaii:
APPLICANT INFORMATION
Last Name:
First Name:
Middle Initial(s):
Suffix:
Nickname / Alias:
Height:
Weight (pounds):
Hair color:
Eye color:
Identifying Marks / Scars (if any):
Residence Addres:
City:
State:
Zip Code:
Phone:
Mailing Address (if different than residence address):
City:
State:
Zip Code:
Phone:
Affiliation Employer:
Address:
City:
State:
Zip Code:
Phone:
CURRENT CERTIFICATION / LICENSURE & PRIOR EXPERIENCE
Do you have a valid Red Cross Lifeguard Training Certificate?
Yes
No.
q
q
If
Yes
, indicate the expiration date:
/
/
Do you have a valid U.S. Coast Guard license to operate the listed watercraft carrying passagners for hire?
Yes
q No.
q
If
Yes
, indicate the expiration date:
Has your license ever been revoked / suspended?
q
Yes
q
No.
/
/
If
Yes (your license previously has been revoked / suspended)
, indicate the reason:
I have
years experience in operating the above listed watercraft.
Has the Department prevoiusly issued you an operator permit?
q
Yes
q
No.
If
Yes
, indicate the type:
Date of Issuance:
/
/
Has your permit ever been revoked / suspended?
q Yes
q No.
If
Yes
, indicate the reason:
Date of Revokation / Suspension:
/
/
AGREEMENT & SIGNATURE
I agree to comply with the provisions of the Hawaii
Administrative Rules as promulgated by the Division of
/
/
Boating and Ocean Recreation applicable to this permit.
Signature of Applicant
Date
Approved | Denied
Form Revised: 07/2011
Official Use Only - Date Received:
Agent Name:
Status:
APPLICATION FOR
COMMERCIAL INSTRUCTOR / OPERATOR PERMIT
Division of Boating and Ocean Recreation
Department of Land and Natural Resources, State of Hawai'i
PERMIT INFORMATION
Application type (
) :
New
Renewal
one
q
q
4
Instructor Type:
q
Surfboard Instructor
q
Canoe Captain
q Thrill Craft Instructor
q
Sailboard Instructor
q
Canoe 2nd Captain
q
Kayak Instructor
Attach
Dive Instructor
q Canoe Learner Steersmam
q
Photo
Operator Type:
Sail Operator (indicate hull type):
Mono-hull
Multi-hull
q
m
m
q
Motorboat Operator:
m
Parasail
m
Shuttle
m
Excursion
m
Dive
Other:
m
Indicate the Ocean Recreation Managment Area
of the ocean waters in the State of Hawaii:
APPLICANT INFORMATION
Last Name:
First Name:
Middle Initial(s):
Suffix:
Nickname / Alias:
Height:
Weight (pounds):
Hair color:
Eye color:
Identifying Marks / Scars (if any):
Residence Addres:
City:
State:
Zip Code:
Phone:
Mailing Address (if different than residence address):
City:
State:
Zip Code:
Phone:
Affiliation Employer:
Address:
City:
State:
Zip Code:
Phone:
CURRENT CERTIFICATION / LICENSURE & PRIOR EXPERIENCE
Do you have a valid Red Cross Lifeguard Training Certificate?
Yes
No.
q
q
If
Yes
, indicate the expiration date:
/
/
Do you have a valid U.S. Coast Guard license to operate the listed watercraft carrying passagners for hire?
Yes
q No.
q
If
Yes
, indicate the expiration date:
Has your license ever been revoked / suspended?
q
Yes
q
No.
/
/
If
Yes (your license previously has been revoked / suspended)
, indicate the reason:
I have
years experience in operating the above listed watercraft.
Has the Department prevoiusly issued you an operator permit?
q
Yes
q
No.
If
Yes
, indicate the type:
Date of Issuance:
/
/
Has your permit ever been revoked / suspended?
q Yes
q No.
If
Yes
, indicate the reason:
Date of Revokation / Suspension:
/
/
AGREEMENT & SIGNATURE
I agree to comply with the provisions of the Hawaii
Administrative Rules as promulgated by the Division of
/
/
Boating and Ocean Recreation applicable to this permit.
Signature of Applicant
Date
Approved | Denied
Form Revised: 07/2011
Official Use Only - Date Received:
Agent Name:
Status:

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