Cg-719b Application For Merchant Mariner Credential (mmc)

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)

OMB No. 1625-0040
Exp. Date: 06/30/2012

Section I – Personal Data See instructions at the end of the application for completing this form.
1. Legal Name: (Last,

First,

Middle

2b. Reference Number (if applicable)
4. Citizenship/Nationality

Suffix)

(Alias(es) or Maiden Name(s) if applicable)

2c. Alien Registration Number (ARN) (if applicable)
5a. Place of Birth (City)

5b. State

5c. Country

2a. SSN

3. Date of Birth (DD/MM/YYYY)
5d. Color of Eyes

5e. Color of Hair

Mariner Information (Please indicate best method(s) of contact by checking the appropriate box(es))
6a. Home Address (PO Box NOT acceptable)
City

6c. Phone Number
State

Zip Code

6b. Delivery/Mailing Address, if different (PO Box acceptable)
City

State

6d. Alternate Phone

6e. Email address
Zip Code

6f. Other

Next of Kin/Emergency Contact (Please indicate best method(s) of contact by checking the appropriate box(es))
7a. Name & Mailing Address, City, State, Zip Code
Same address as above

7b. Relationship (Optional)
7c. Phone Number (Optional)

City

State

Zip Code

7d. Cell Phone (Optional)
7e. Email Address (Optional)

Section II – Requested Coast Guard Credential(s) See instructions at the end of the application for completing this form.
Credential or Endorsement Type(s) Requested:
Endorsement Category

Transaction Type (Check All That Apply: See Instructions for Definitions and Additional
Requirements for the transaction below)
Original

Renewal

Duplicate

Raise of Grade or
New Endorsement

Increase in Scope

Document of
Continuity

Officer
Qualified Rating
Entry Level
STCW
Description of Endorsement(s) Desired: Include all appropriate information – Officer (i.e. Deck – Master/Mate/Propulsion/Tonnage/Route OR Engineer
Grade – 3rd AE; DDE/Propulsion/Horsepower) Ratings (i.e.: Able Seaman, Tankerman, QMED, Lifeboatman)

FOR RENEWAL TRANSACTIONS ONLY: I request to have my merchant mariner credential (MMC) issued immediately and decline having its
issuance coincide with my previous credentials expiration date.
If I am not approved for the endorsement I have requested, I wish to be approved for the highest endorsement for which I am qualified (e.g. I want AB
Limited if I am not approved for AB Unlimited)

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DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)

OMB No. 1625-0040
Exp. Date: 06/30/2012

Section III – Mariner’s Consent/Certification - Check all that apply. See instructions at the end of the application for completing this form.
1.

Transportation Worker’s Identification Credential (TWIC)

I have previously enrolled for a TWIC with TSA and am exempt from holding a valid TWIC.

2. Mariner Outreach System (MOS) (Optional): I consent to voluntary participation in the Mariner Outreach 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 either by subsequent application or by sending a signed notice of revocation to the U.S. Coast Guard National Maritime Center, 100
Forbes Dr., Martinsburg, WV 25404. For more information on MOS, please visit https://mos.marad.dot.gov/
Yes, I would like to participate
3.

No

Yes

No thanks, I do not wish to participate at this time

I have been a user of/or addicted to a dangerous drug, including marijuana, within the last 10 years.

4.
I have attached a signed statement of explanation for all convictions not previously disclosed to the Coast Guard on a prior Merchant Mariner
Credential Application. Per 46 CFR Part 10, 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
or 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.
5.
National Driver Registry (NDR) (Mandatory for Original, Renewal, or new Officer Endorsement): 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. NOTE: Not required for Document of Continuity applicants.
• I understand the USCG will make the information received from the NDR available to me for review and written comment prior to disapproving my
application or taking any action against my Merchant Mariner’s Credential. Authority: 46 U.S.C. 7101(g), 46 U.S.C. 7302(c), and 46 U.S.C 7505.
6.
I understand that a Document of Continuity is not valid for use in accordance with 46 CFR 10.227(e)(2)(ii) and aware of the requirements to
obtain an MMC.
7.

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

8. Third Party (Optional)
* By checking the following boxes, I am authorizing release of information to the third party as indicated below. If a selection is made, please provide
the Name of the Organization or Third Party, Address, and Phone Number. Additional Third Party release information can be attached separately.
8a.

Safety and Suitability

8b.

Medical

8c.

Professional qualifications, certification records, or Sea Service

8d.

Merchant Mariner Credential Delivery

8e.

Act on my behalf in all matters pertaining to the processing of my
current USCG credential application.

Name of Organization or Third Party
Organization Point of Contact (if applicable)
Address
City

State

Zip Code

Phone Number

9. Certification:
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 understand an application determined to be fraudulent may result in the denial of my application for one year from the date of submission, even if the
fraudulent information was not by itself cause for denial or prosecution.
• I certify that the information on this application is true and correct.
• I certify that, if this application is being filed before the minimum assessment period has elapsed, I've included evidence of suitability for service in the
merchant marine. (If this is not included, then the application will not be processed by the Coast Guard.)

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DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)

OMB: 1625-0040
Expires: 06/30/2012

Section III – Mariner’s Consent/Certification (Continued)
10. Oath (Mandatory for Original Only):
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.
11. Applicant’s Signature

X Signature of Applicant

Date

X Signature of Coast Guard Official or Commissioner for Oath

Date

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 9 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, 100 Forbes Dr.
Martinsburg, WV 25404 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.

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. § 7101, 7302, 7305, 7314, 7316, 7319, 7502, 31
U.S.C. § 7701, PUBLIC LAW 93-579, SECTION 7. B. SEE 46 CFR PARTS 10, 11, AND 12.

2.

PRINCIPLE PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED: A. TO ESTABLISH ELIGIBILITY FOR A MERCHANT
MARINER'S CREDENTIAL, DUPLICATE CREDENTIAL, OR ADDITIONAL ENDORSEMENTS ISSUED BY THE U.S. COAST GUARD. B. TO
ESTABLISH AND MAINTAIN A CONTINUOUS RECORD OF THE PERSONS CREDENTIAL 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. 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.

4.

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: DISCLOSURE OF
SOME INFORMATION, SPECIFICALLY THE SOCIAL SECURITY NUMBER (SSN), IS MANDATORY. THE SSN IS A METHOD USED TO
ASSOCIATE A MARINER WITH A PARTICULAR MARINER RECORD AS WELL AS ASSOCIATING ANY PAYMENT(S) TO THAT RECORD.
OTHER INFORMATION IS VOLUNTARY, BUT FAILURE TO PROVIDE MAY RESULT IN NON-ISSUANCE OF THE REQUESTED
CREDENTIAL(S).

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APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC) INSTRUCTIONS
Instruction: See Figure 1 (additional Requirements) on the last page of these instructions for further guidance
regarding information you may be required to submit with the application. Attach additional sheets if you cannot fit
all information in a block.
Section I: Personal Data
I.1

Legal Name: Enter complete legal name. Include any aliases you have used and your maiden or prior name(s).

I.2a

Social Security Number: If you are applying for an original credential, enter your SSN.

I.2b

Reference Number: If you have been credentialed by the Coast Guard in the past, enter your reference number.

I.2c

Alien Registration Number: If you are a legal alien, also enter your alien registration number (ARN).

I.3

Date of Birth: If applicant is under 18 years of age, notarized statement from legal guardian is required. Attach a notarized statement, signed by a
parent or legal guardian, authorizing the Coast Guard to issue a credential.

I.4

Citizen: If not a U.S. citizen, please indicate country of nationality.

I.5a-c

Place of Birth: City, State, Country. If born outside the United States, leave State blank.

Section I: Mariner Contact Information (Please indicate best method(s) of contact by checking the appropriate
box(es)). If NMC is unable to contact you, it could cause delays in processing your application)
I.6a

Home Address: Principle place of residence. PO Box is NOT acceptable.

I.6b

Delivery/Mailing Address: The address to which you want all correspondence and issued credentials sent. If blank, correspondence and
credentials will be sent to the Home Address.

I.6c

Phone Number: Provide a primary phone number.

I.6d

Alternate Phone: Provide an alternate phone number if available.

I.6e

E-mail Address: The NMC may attempt to contact you via e-mail. You will receive automated e-mail updates regarding the status of your
application.

I.6f.

Other: Please provide additional means of communicating with you (satellite phone, work phone, etc.) if available.

Next of Kin/Emergency Contact: (Check the box for preferred contact method)
I.7a

Next of Kin / Emergency Contact: Name & Mailing Address, City, State, Zip Code

I.7b

Relationship: Provide relationship status to next of kin listed on application. (i.e. Mother, Father, Spouse)

I.7c

Phone Number: Phone number to contact the person listed in the event of an emergency.

I.7d

Alternate Phone: Provide a cellular phone number, if available.

I.7e

E-mail Address: Provide an e-mail address for Next of Kin listed.

Section II: Requested Coast Guard Credential(s)
Transaction Type: Place a check in the box for each transaction type that applies.
Original: An applicant must apply for an original MMC if they have never held any Coast Guard issued credential or if the first credential issued to applicant
after their previous credential was revoked pursuant to 46 CFR. Complete the application and ensure all mandatory documents are contained with
application.
Renewal: A credential may be renewed at any time during its validity and for one year after expiration; you must be qualified to renew all Domestic /STCW
Officer and Rating endorsements to receive a new five year expiration date. An MMC renewal-only transaction will automatically be issued with a date that
coincides with the expiration date of your previous credential or a date that is 8-months from the time the Coast Guard accepted your application,
whichever is sooner. Page 1, Section II of this form provides you the opportunity to decline this post-dating feature and receive your MMC immediately.
Duplicate: In the event of a lost credential, a statement describing the circumstances of the loss must be submitted with the application. The duplicate will
have the same authority, wording and expiration date as the lost credential. If a person loses a credential by shipwreck or other casualty that causes
damage to a ship, a duplicate will be issued free of charge as per 46 CFR. If a person loses a credential by other means and applies for a duplicate, the
appropriate fee set out in 46 CFR must be paid. No application from an alien for a duplicate credential will be accepted unless the alien complies with the
requirements of 46 CFR.

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Raise of Grade or New Endorsement: Is defined as an increase in the level of authority and responsibility associated with an officer or rating
endorsement. You must first hold an MMC before an endorsement is issued for a Raise of Grade and/or Increase in Scope (i.e. Raise of Grade of 3rd mate
to 2nd mate will not change the expiration date unless specifically requested and renewal requirements are met for all other endorsements on MMC).
Increase in Scope: Increase in scope may include a change in horsepower, propulsion or tonnage limitations, or geographic route restrictions. You must
first hold an MMC before an endorsement is issued for a Raise of Grade and/or Increase in Scope. Endorsements maintain the same expiration date as the
credential being endorsed.
Document of Continuity: Documents of continuity do not expire, do not require medical or security evaluations, and do not require fees. They are a record
of competencies previously held and do not authorize the holder to sail in any capacity listed thereon.
Description of MMC or Endorsement Desired: All Mariners will receive a single Merchant Mariner Credential. Describe all capacities and limitations both
domestic and STCW including tonnage, waters, propulsion mode, horsepower, ratings (Ordinary Seaman, Able Seaman, QMED-Oiler, etc.), purser, doctor,
radio operator, continuity, etc.
NOTE: Entry Level Ratings: There are no professional requirements needed when applying for entry level credential. Ratings may include Ordinary
Seaman, Wiper, and/or Stewards Department / Stewards Department (Food Handler - F.H.). Per 46 CFR Part 10, applicants requesting Stewards
Department (F.H.) will be required to submit a statement attesting applicant is free from communicable disease.

Section III: Mariners Consent/Certification
III. 1

TWIC Information: Unless specifically exempted, the Coast Guard must have evidence that you hold a valid TWIC or, for original applicants, that
you have enrolled for a TWIC and are awaiting the results. With the exception of applicants for Documents of Continuity, no mariner credential will
be issued until the Coast Guard receives information from the TSA that you are currently or have previously been approved to hold a TWIC.
Exemptions from holding a valid TWIC:
a.

Mariners applying for a Document of Continuity are not required to enroll for a TWIC.

b.

Mariners who are inactive or not operating under the authority of their credential. This exemption will cease to exist if the mariner
subsequently chooses to work under the authority of their credential.

c.

Mariners who serve on vessels that are not required to have a vessel security plan. These vessels include:
i.

Uninspected passenger vessels of less than 100 gross register tons (GRT); and

ii.

Vessels inspected under subchapter T of Title 46 Code of Federal Regulations, except those on international voyages; and

iii.

Towing vessels not involved in towing barges inspected under 46 CFR subchapters D, I or O; and

iv.

Towing vessels involved in fleeting, docking, or ship assist as excepted in Title 33 CFR, Section 104.105(a)(11).

This exemption will cease to exist if the mariner subsequently chooses to work under the authority of their credential on vessels not specifically exempted.
III. 2

Mariner Outreach System (MOS): This is an optional program. Applicant will need to select whether Yes, they would like to participate, or No,
they do not wish to participate in the Mariner Outreach System, by selecting either of the check boxes.

III.3

Drug Use: Has applicant used dangerous drugs, including marijuana within the past 10 years? Check YES or NO. Applicant must provide evidence
of having passed a chemical test for dangerous drugs or qualify for an exemption from testing as per 46 CFR.

III.4

Convictions: Original applicants are required to list all convictions including military court martials and driving related convictions other than minor
traffic violations. For renewals and endorsements, list all of those convictions not previously reported to the Coast Guard on a Merchant Mariner
Credential application. If you are unsure what you previously reported, you are encouraged to provide a complete list of all convictions. Failure to
report convictions will delay your credential and may result in denial.

III.5

National Driver Registry (NDR): No MMC will be issued as an original or reissued with a new expiration date, and no new officer endorsement
will be issued, unless the applicant consents to an NDR check as per 46 USC 7505.

III.6

Continuity: Credentials issued for continuity purposes are not valid for use.

III.7

Consent: Applicants under the age of 18 must attach a notarized statement of parental/guardian consent.

III.8

Third Party Release: If you want the NMC to be able to discuss, release, or receive information/documents regarding your credential application
with a third party (spouse, employer, school, union, etc.) you must provide specific guidance to the NMC regarding what issues we may discuss
and with whom. You may allow release of all information to certain individuals or entities. If you limit the release of certain information you must be
specific by making a selection on the application or by attaching additional documentation. For each selection made, ensure the Name of the
Organization or Third Party, Organization Point of Contact (if applicable), Address and Phone Number is completed. If you wish to provide multiple
Third Party Releases, attach additional pages as needed. A sample may be found on the NMC website: http://www.uscg.mil/nmc/ .

III.9

Certification: Applicant certifies that the information provided is true and correct.

III.10

Oath: Every person who applies for an original MMC must first take an oath. The applicant must sign and date the application stating they have
taken the oath. Failure to sign will result in the application being returned. Per 46 CFR 10.225(c), an oath may be administered by any Coast
Guard designated individual or any person legally permitted to administer oaths in the jurisdiction where the person taking the oath resides.

III.11

Signature and Date: Failure to sign and date the application will result in the application being returned.

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Figure 1:
Attachment to Include:
The following attachments are
required for transactions to the
right.

Endorsement Categories and Transaction Types
Original Entry
Level Rating
Endorsement

Qualified
Original Rating
Endorsement

Original
Officer
Endorsement

Renewal

User Fees: Copy of Receipt
from www.pay.gov

✔

✔

✔

Oath (For original only)

✔

✔

✔

✔ *

✔

Complete Physical CG 719K
(Last 12 Months)

✔

✔

✔

Doc. Of
Continuity

✔

✔
✔

✔

Three Letters of
Recommendation

✔

✔

Copy of All Current
Credential(s)
Sea Service
Notarized Statement from
Legal Guardian for Applicants
< 18 YOA

Increase in
Scope

✔

Complete Physical CG 719K
(Approved Last 36 Months)

Drug Screen

Raise of
Grade/New
Endorsement

✔

Statement of Loss (Duplicate)

Complete Physical CG 719K/E
(Last 12 Months, Entry Level
Applicants Only)

Duplicate

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

* If the only qualified rating being sought is Lifeboatman, then CG 719K/E submission is acceptable.
Any questions or for assistance, contact NMC Customer Service Center: 1-888-IASKNMC
(1-888-427-5662) or http://www.uscg.mil/nmc/contact_iasknmc.asp

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