CG-719C Disclosure Statement for Narcotics, DWI/DUI, and/or Othe

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard

OMB No. 1625-0040
Exp. Date: 01/31/2016

DISCLOSURE STATEMENT FOR NARCOTICS, DWI/DUI, AND/OR OTHER CONVICTIONS (OPTIONAL FORM CG-719C)

------ Instructions -----Who should submit this form?
Original Merchant Mariner Credential (MMC) applicants are required to list all convictions including military court martial, driving related convictions other than
minor traffic violations, and foreign court convictions. For renewals and endorsements, list all of those convictions not previously reported to the Coast Guard
on a MMC 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. You may use this form for the disclosure required by 46 CFR 10.211 to report your convictions,
or you may use this form as a guide to provide your written explanation.
If an applicant applies before the minimum assessment period for his or her conviction, he or she must submit evidence of suitability for service. This may
include: proof of completion of alcohol or drug abuse rehab; membership in a rehab or counseling group; character references; steady employment; and
successful completion of parole or probation. 46 CFR 10.211(i)

CONVICTION DEFINED (46 CFR 10.107)
A. An applicant will be considered to have received a conviction of a criminal Felony, Misdemeanor or a National Driver Register (NDR) offense if he or
she:
1. Was Found Guilty, or Pleaded Guilty,
2. Pleaded No Contest,
3. Was granted Deferred Adjudication,
4. Was Required to:
(a) Attend Classes,
(b) Make contributions of Time or Money,
(c) Receive Treatment,
(d) Submit to any manner of Probation or Supervision, or,
(e) Forego Appeal of a trial court's conviction.
B. A conviction of more than one offense at a single trial will be considered to be multiple convictions.
C. Expunged convictions must be reported unless the expungement was based upon a showing that the court's earlier conviction was in error.

Section I: Applicant Information
•
•
•
•

Legal Name - Enter complete legal name and include aliases used and/or maiden name(s).
Reference Number - If you have been credentialed by the Coast Guard in the past, enter your reference number.
Social Security Number - If you are applying for an original credential, enter your SSN.
Date of Birth - If applicant is under 18 years of age, notarized statement from legal guardian is required.

Section II: Conviction and/or Drug Use Disclosure
•
•
•
•
•
•
•

Convicted of - Enter the exact charge(s) for which you were convicted.
City - Enter the city/town/parish where you were convicted.
State/Country - Enter the state/country where you were convicted.
Date - Enter the date of conviction.
Court findings - Enter the court's final determination of charges to include amended or added charges.
Court sentence/requirements - Enter length of an incarceration ordered by court, probation (probation officer name and phone number), fines, classes,
driving privilege suspended/revoked and reinstatement date, etc.)
What happened - Provide brief description of events leading to arrest to include the Arresting Agency.

Section III: Acknowledgement and Certification
•
•

Signature of Applicant - Acknowledge that you have read and understand the definition of conviction and certify that the information on this Disclosure
Statement for Narcotics, DWI/DUI, and/or other Convictions form is true and correct.
Date - Enter current date.

PRIVACY NOTICE
Authority: 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7502, 46 C.F.R. 10.301
Purpose: The information is collected by the Coast Guard to determine whether an applicant meets the regulatory standards for issuance of a U.S. Merchant
Mariner Credential (MMC). The Coast Guard evaluates an applicant's qualifications to determine compliance with the national and international requirements for
issuance of the MMC, any endorsement within the MMC, and medical certificate.
Routine Uses: The information is used by authorized Coast Guard personnel who have a need for the record to determine whether an applicant is a safe and
suitable person and qualifies for the MMC, any endorsement within the MMC, and medical certificate. In addition, the Coast Guard uses this information to
maintain and update records of merchant mariner documentation transactions. The information will not be shared outside of DHS except in accordance with the
provisions of DHS/USCG-030 Merchant Seamen's Records System of Records, 74 FR 30308 (June 25, 2009).
Disclosure: Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may result in the non-issuance
of the MMC, any endorsement within the MMC, and medical certificate.
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 United States Coast Guard estimates that the average burden for completing this form is 10 minutes. You may submit any comment concerning the
accuracy of this burden estimate or any suggestions for reducing the burden to the Chief, Office of Merchant Mariner Credentialing, 2703 Martin Luther King, Jr.
Ave, S.E., STOP 7509, Washington, D.C., 20593-7509.
CG-719C (04/17)

Reset

Page 1 of 2

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0040

U.S. Coast Guard

Exp. Date: MM/DD/YYYY

DISCLOSURE STATEMENT FOR NARCOTICS, DWI/DUI, AND/OR OTHER CONVICTIONS (OPTIONAL FORM CG-719C)
Section I: Applicant Information (Please Print)
1. Legal Name

Last

First

2. Reference Number

Middle

3. Social Security Number (000-00-0000)

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

4. Date of Birth (MM/DD/YYYY)

Section II: Conviction and/or Drug Use Disclosure (Please Print)

.

Failure to disclose the details requested below for every question marked YES in Section III of the CG-719B will delay the application process.
Please attach additional sheets as necessary.

DANGEROUS DRUG
USE DETAILS (if any)

6. Month/Year of Last Use (MM/YYYY)

5. Type of Drug

CONVICTION DETAILS
a. Convicted of

CONVICTION 1
b. City

e. Court findings: (deferred adjudication, guilty plea/no
contest, etc.)

c. State/Country

d. Date (MM/DD/YYYY)

f. Court sentence/requirements: (length of any incarceration ordered by
court, probation [probation officer name and phone number], fines,
classes, driving privilege suspended/revoked, and reinstatement date, etc.)

g. What happened and did you comply with/are you in compliance with court order (Provide brief description of events and Arresting Agency)

CONVICTION 2
a. Convicted of

b. City

e. Court findings: (deferred adjudication, guilty plea/no
contest, etc.)

c. State/Country

d. Date (MM/DD/YYYY)

f. Court sentence/requirements: (length of any incarceration ordered by
court, probation [probation officer name and phone number], fines,
classes, driving privilege suspended/revoked, and reinstatement date, etc.)

g. What happened and did you comply with/are you in compliance with court order (Provide brief description of events and Arresting Agency)

Section III: Acknowledgement and Certification
I acknowledge that I have read and understand the definition of "conviction" in the instructions, and I certify that the information on this
Disclosure Statement for Narcotics, DWI/DUI, and or Other Convictions form is true and correct.
Signature of Applicant

CG-719C (04/17)

Date (MM/DD/YYYY)

Reset

Page 2 of 2