Include, at a minimum, the name of the condition, approximate date of diagnosis, treatment, current status of the condition, limitations of the condition, andĪny additional information as appropriate. The Medical Practitioner's discussion should III(b) The Medical Practitioner must review and discuss all conditions reported by the applicant in Section III(a). Is present, regardless of treatment status. Applicants should check YES if: 1) they have had a previousĭiagnosis, or treatment for the condition by a health care provider 2) they are currently under treatment or observation for the condition or 3) the condition III(a) Applicants must report their relevant medical conditions to the best of their knowledge. Section III: Medical Conditions - To be completed by the Applicant and the Medical Practitioner The Medical Practitioner should initial and date at the bottom of each page of the application, where indicated. Refer to instructions provided in this section. Section II: Food Handler Certification - To be completed by the Medical Practitioner If nothing is selected, the Coast Guard will not accept the application. Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) (optional).Įndorsement held or sought - Applicants should select all options that apply. Regarding the status of your application. Primary Phone Number - Provide a primary phone number.Īlternate Phone Number - Provide an alternate phone number (optional).Į-mail Address - (Optional) If provided, the National Maritime Center (NMC) may attempt to contact you via e-mail. If blank, correspondence and certificates will be PO Box is not acceptable.ĭelivery/Mailing Address - The address to which you want all correspondence and issued certificates sent. Home Address - Principle place of residence. Mariner Reference Number or Social Security Number - If you have held a Coast Guard credential in the past, enter your reference number. Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner (MP)ĭate of Birth - If applicant is under 18 years of age, attach a notarized statement, signed by a parent or guardian, authorizing the Coast Guard to issue a Registered Pilots must be conducted by a licensed medical doctor.
All exams, tests and demonstrations must be performed, witnessed or reviewed by a physician, physician assistant, or nurse practitioner licensed by a state The Coast Guard will not accept an application for a medical certificate without a reference number or a Merchant Mariner Credential (MMC).ġ. The medical certificate will be restricted to entry-level only.ģ.
(Physical Examination) of the CG 719K DO NOT have to be completed. Sections III (Medical Conditions), IV (Medications) and V Mariners applying for or holding a merchant mariner credential with only an entry-level endorsement who serve on a vessel not subject to the InternationalĬonvention on Standards of Training, Certification and Watchkeeping (STCW) but who request a medical certificate that satisfies the Maritime LaborĬonvention (MLC), AND want to be qualified for lookout duties should submit this form. Guidanceįor completion of this form can be found at. Applicants seeking a Medical Certificate are required to complete this form and submit all 10 pages, including instructions, to the U.S. Instructions -Who must submit this form?ġ. APPLICATION FOR MEDICAL CERTIFICATE (FORM CG-719K)
0 kommentar(er)
