Cg-719b Application For License As Officer, Staff Officer, Opera

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD

Application for License as an Officer, Staff Officer, or
Operator and for Merchant Mariner's Document

CG-719B (Rev 03/04)

(Maiden Name if applicable)

Date of Birth (Month, Day, Year)
_____ / _____ / _____
Color of Eyes

Page 1

(For CG Use Only) Date Application Received

Section I - Personal Data
Name (Last, First, Middle)

OMB 1625-0040
Expires 07/31/2009

Social Security Number

Place of Birth (City, State, Country)
Color of Hair

Country of Citizenship
Height

Mailing Address, City, State, Zip Code (PO Boxes are acceptable)

Next of Kin’s Name and Mailing Address, City, State, Zip Code

_________ft________in
Phone Number
(
)
FAX Number
(
)
E-mail Address

Weight

___________lbs

Relationship
Next of Kin's Phone Number
(
)
Next of Kin's E-mail Address

Parental or Guardian's Consent

I am under 18 years old and a notarized statement of parental/guardian consent is attached.

Section II - Type of Transaction
Transaction

Original

Renewal

Raise in Grade

Endorsement

Duplicate*

License
Merchant Mariner's Document (MMD)
STCW Certificate
Certificates of Registry
Certificate of Discharge Sea Service

*If requesting a duplicate for a lost or stolen License/MMD attach a signed statement explaining how,
when and where your credentials were lost or stolen and your efforts to recover them.
Applying for:

Grade of License (include tonnage, waters, propulsion mode, horsepower, etc.); or MMD rating (Able Seaman, QMED-Oiler, etc.)

State Current or Previous License/Merchant Mariner’s Document
Description of License/Merchant Mariner’s Document

Place of Issue

Previous Edition Obsolete

Date of Issue

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-719B (Rev 03/04)

Application for License as an Officer, Staff Officer, or
Operator and for Merchant Mariner's Document

OMB 1625-0040
Expires 07/31/2009

Page 2

Section III - Narcotics, DWI/DUI, and Conviction Record Conviction means found guilty by judgment or by plea
and includes cases of deferred adjudication (no contest, adjudication withheld, etc.) or where the court required you to attend classes, make
contribution of time or money, receive treatment, submit to any manner of probation or supervision, or forgo appeal of a trial court finding.
Expunged convictions must be reported unless the expungement was based upon a showing that the court’s earlier conviction was in error.
Yes
No

(X)

(X)

Indicate your answers to the following questions; sign and date at the bottom of this section.

Have you ever been convicted of violating a dangerous drug law of the United States, District of Columbia, or any state, or territory of
the United States? (This includes marijuana.) (If yes, attach statement)
Have you ever been a user of/or addicted to a dangerous drug, including marijuana? (If yes, attach statement)
Have you ever been convicted by any court – including military court – for an offense other than a minor traffic violation?

(If yes, attach statement)

Have you ever been convicted of a traffic violation arising in connection with a fatal traffic accident, reckless driving or racing on the
highway or operating a motor vehicle while under the influence of, or impaired by, alcohol or a controlled substance?

(If yes, attach statement)

Have you ever had your driver's license revoked or suspended for refusing to submit to an alcohol or drug test?

(If yes, attach statement)

Have you ever been given a Coast Guard Letter of Warning or been assessed a civil penalty for violation of maritime or environmental
regulations? (If yes, attach statement)
Have you ever had any Coast Guard license or document held by you revoked, suspended or voluntarily surrendered?

(If yes, attach statement)

I have attached a statement of explanation for all areas marked “yes” above. I signed this section with full
understanding that a false statement is grounds for denial of the application as well as criminal prosecution and
financial penalty. I understand that failure to answer every question will delay my application.

X Signature of Applicant agreeing to the above statement

Date

Section IV – Character References

(For Original License Applicants Only)
I am an Original License Applicant and have attached three letters of written recommendation.

Section V - Mariner's Consent
National Driver Registry (NDR) (Mandatory): I authorize the National Driver Registry to furnish the U.S. Coast
Guard (USCG) information pertaining to my driving record. This consent constitutes authorization for a single access to the
information contained in the NDR to verify information provided in this application. I understand the USCG will make the
information received from the NDR available to me for review and written comment prior to taking any action against my
License or Merchant Mariner’s Document. Authority: 46 U. S. C. 7101(g) and 46 U. S. C. 7302(c).

X Signature of Applicant

Date
Mariner's Tracking System (Optional): I consent to voluntary participation in the Mariner’s Tracking System to be used

by the Maritime Administration (MARAD) in the event of a national emergency or sealift crisis. In such an emergency,
MARAD would disseminate my contact information to an appropriate maritime employment office to determine my availability
for possible employment on a sealift vessel. Once consent is given, it remains effective until revoked in writing. Send signed
notice of revocation to the USCG National Maritime Center (NMC-4A), 4200 Wilson Blvd., Suite 630, Arlington, VA 222031804

X Signature of Applicant

Date

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-719B (Rev 03/04)

Application for License as an Officer, Staff Officer, or
Operator and for Merchant Mariner's Document

OMB 1625-0040
Expires 07/31/2009

Page 3

Section VI - Certification and Oath
Certification (Mandatory)

Whoever, in any manner within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals or
covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or
uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, violates the U. S.
Criminal Code at Title 18 U. S. C. 1001 which subjects the violator to Federal prosecution and possible incarceration, fine or both.
I certify that the information on this application is true and correct and that I have not submitted any application of any type to the Officer-inCharge, Marine Inspection in any port and been rejected or denied within 12 months of this application.

X Signature of Applicant agreeing to the above statement

Date

Oath (For originals only. Coast Guard official must witness applicant signature.)

I do solemnly swear or affirm that I will faithfully and honestly, according to my best skill and judgment, and without concealment and
reservation, perform all the duties required of me by the laws of the United States. I will faithfully and honestly carry out the lawful orders of
my superior officers aboard a vessel.

X Signature of Applicant

Date

Signature of Coast Guard Official

Date

U.S. Coast Guard Use Only
Section VII – REC Application Approval
(Application has been approved on this date)
Signature of Approving Official

REC

Date

Section VIII – REC Citizenship Verification & Credential Issuance
Indicate Proof of Citizenship below (For non U.S. also include I.N.S. Alien Registration #)
License Endorsement(s) Issued

Issue Number
Expiration Date

Document Rating(s) Issued

License Serial Number

MMD Serial Number
Expiration Date

Check box if corresponding STCW certificate was issued.
Signature of Issuing Official

REC

Date

Section IX – NMC Verification of Duplicate Transactions
Ratings/Endorsements Authorized

Signature of Approving NMC Official: ____________________________________________________Date: __________________

DEPARTMENT OF
HOMELAND SECURITY
U.S. COAST GUARD
CG-719B (Rev 03/04)

Application for License as an Officer, Staff Officer, or
Operator and for Merchant Mariner's Document

OMB 1625-0040
Expires 07/31/2009

Page 4

PRIVACY ACT STATEMENT
In accordance with 5 U. S. C. 552a(e)(3), THE FOLLOWING INFORMATION IS PROVIDED TO YOU WHEN SUPPLYING PERSONAL INFORMATION TO
THE U.S. COAST GUARD.
1.

AUTHORITY WHICH AUTHORIZED THE SOLICITATION OF INFORMATION
A. 46 U. S. C. 7302, 7305, 7314, 7316, 7319, AND 7502
B. SEE 46 CFR PARTS 10 AND 12.

2.

PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED.
A. TO ESTABLISH ELIGIBILITY FOR A MERCHANT MARINER’S DOCUMENT, DUPLICATE DOCUMENTS, OR ADDITIONAL
ENDORSEMENTS ISSUED BY THE COAST GUARD.
B. TO ESTABLISH AND MAINTAIN A CONTINUOUS RECORD OF THE PERSONS DOCUMENTATION TRANSACTIONS.
C. PART OF THE INFORMATION IS TRANSFERRED TO A FILE MANAGEMENT COMPUTER SYSTEM FOR A PERMANENT RECORD.

3.

THE ROUTINE USES WHICH MAY BE MADE OF THE INFORMATION:
A. TO MAINTAIN RECORDS REQUIRED BY 46 U. S. C. 7319 AND 7502.
B. TO ENABLE ELIGIBLE PARTIES (i.e. the mariner’s heirs or properly designated representative) TO OBTAIN INFORMATION.
C. TO PROVIDE INFORMATION TO THE U.S. MARITIME ADMINISTRATION FOR USE IN DEVELOPING MANPOWER STUDIES AND
TRAINING BUDGET NEEDS.
D. TO DEVELOP INFORMATION AT THE REQUEST OF COMMITTEES OF CONGRESS.
E. TO PROJECT BILLET ASSIGNMENTS AT COAST GUARD MARINE INSPECTION/SAFETY OFFICES.
F. TO PROVIDE INFORMATION TO LAW ENFORCEMENT AGENCIES FOR CRIMINAL OR CIVIL LAW ENFORCEMENT PURPOSES.
G. TO ASSIST U.S. COAST GUARD INVESTIGATING OFFICERS AND ADMINISTRATIVE LAW JUDGES IN DETERMINING
MISCONDUCT, CAUSES OF CASUALTIES, AND APPROPRIATE SUSPENSION AND REVOCATION ACTIONS.
WHETHER OR NOT DISCLOSURE OF SUCH INFORMATION IS MANDATORY OR VOLUNTARY (Required by law or optional) AND THE EFFECTS
ON THE INDIVIDUAL, IF ANY, OF NOT PROVIDING ALL OR PART OF THE REQUESTED INFORMATION IS VOLUNTARY, DISCLOSURE OF
THIS INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE MAY RESULT IN NON-IISUANCE OF THE REQUESTED DOCUMENT(S).

4.

“An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control
number.”
“The Coast Guard estimates that the average burden for this report is 10 minutes. You may submit any comments concerning the accuracy of this
burden estimate or any suggestions for reducing the burden to: Commanding Officer, U. S. Coast Guard National Maritime Center, 4200 Wilson Blvd,
Suite 630, Arlington, VA 22203-1804 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.”