I hereby voluntarily waive my Privacy Act Rights with respect to Grossetti License Consulting having full access to any and all license, Merchant Mariner's Document, and/or suspension and revocation records or files in the possession of the United States Coast Guard.
This waiver shall remain in effect until canceled in writing by myself or my duly authorized representative.
Printed or Typed Full Name:________________________________________
Signature:______________________________________________________
Date:_________________________________________________________
Date of Birth:___________________________________________________