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Instructions - : U.S. Coast Guard
Instructions - : U.S. Coast Guard
1625-0040
U.S. Coast Guard Exp. Date: 01/31/2016
APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)
------ Instructions ------
Remove Instructions before submitting Application
Who must submit this form?
Applicants seeking a Merchant Mariner Credential (MMC), whether original, renewal, duplicate, raise of grade, or a new endorsement on a previously issued
MMC.
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 Primary Phone Number - Provide a primary phone number.
I.6d Alternate Phone Number - 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 Primary Phone Number - Phone number to contact the person listed in the event of an emergency.
I.7d Alternate Phone Number - Provide a cellular phone number, if available.
I.7e E-mail Address - Provide an e-mail address for Next of Kin listed.
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 Part 10. 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 4, 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 Part 10. If a person loses a credential by other means and applies for a duplicate, the
appropriate fee set out in 46 CFR Part 10 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.
IV.3 Consent: Applicants under the age of 18 must attach a notarized statement of parental/guardian consent.
IV.4 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/.
IV.5 Certification: Applicant certifies that the information provided is true and correct. 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 by 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.
IV.6 Signature and Date: Failure to sign and date the application will result in the application being returned.
The following attachments are Original Entry Qualified Raise of USRP Certificate of
Original Officer Doc. Of
required for transactions to the Level Rating Original Rating Renewal Duplicate Grade/New Endorsement Registry
Endorsement Continuity
right. Endorsement Endorsement Endorsement (see note) (Original)
Drug Screen
46 CFR 10.225(b)(5)
Sea Service
46 CFR Parts 10, 11, 12 and 13 * **
* A pilot association letter of attestation will be accepted for First Class Pilots.
** Sea Service minimum for USRP Endorsement: 24 months licensed service aboard vessel of 4,000 GRT (incl waters navigated: oceans; coastal; inland lakes,
bays and sounds; rivers; and Great Lakes) Include Vessel name, Official Number/State Registration Number, GRT, Waters Navigated, Licensed Position, Dates
Served on Vessel, and Number of Total days served.
NOTE: When ONLY applying for an original or renewal of a USRP endorsement, scan completed application along with any additional supporting
documentation and email to [email protected] or send via regular mail to:
Commandant (CG-WWM-2)
ATTN: Great Lakes Pilotage Division
U.S. Coast Guard: Stop 7509
2703 Martin Luther King Jr. Ave., SE
Washington, DC 20593-7509
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
2a. SSN (for Original only) 2b. Reference Number (if applicable) 2c. Alien Registration Number (ARN) (if applicable) 3. Date of Birth (MM/DD/YYYY)
4. Citizenship/Nationality 5a. Place of Birth (City) 5b. State 5c.Country 5d. Color of Eyes 5e. Color of Hair
Mariner Information (Please indicate best method(s) of contact by checking the appropriate box(es)).
Next of Kin/Emergency Contact (Please indicate best method(s) of contact by checking the appropriate box(es).) (Optional)
Officer
Qualified Rating
Entry Level
STCW
Description of Endorsement(s) Desired: Include all appropriate information - Officer (i.e. Deck - Master/Mate/Propulsion/Tonnage/Route/United States
Registered Pilot OR Engineer Grade - 3rd AE; DDE/Propulsion/Horsepower) Ratings (i.e.: Able Seaman, Tankerman, QMED, Lifeboatman) (Please Print)
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.
CG-719B (01/14) Page 4 of 6 Reset
DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 01/31/2016
APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)
Section III: Safety and Suitability
1. Transportation Worker's Identification Credential (TWIC) - I have previously enrolled for a TWIC with TSA and I am exempt from holding a valid TWIC
under Coast Guard Policy Letter 11-15. I understand that a name based safety and suitability check could significantly delay the processing of my
Merchant Mariner Credential Application.
2. Convictions and Drug Use (NOT PREVIOUSLY DISCLOSED): If you answer Yes to ANY of the below questions complete the CG-719C or its equivalent for
each question marked Yes
a) Have you ever been a user of/or addicted to a dangerous drug, including marijuana, within the last 10 years? Yes No
b) Have you ever been convicted of violating a dangerous drug law of the United States, District of Columbia, or any state, or Yes No
territory of the United States?
c) Have you ever been convicted by any court-including military court - for an offence other than a minor traffic violation? Yes No
d) Have you ever been convicted of a traffic infraction arising in a connection with a fatal traffic accident, reckless driving or racing Yes No
on a highway or operating a motor vehicle while under the influence of, or impaired by, alcohol or a controlled substance?
e) Have you ever had your driver's license revoked or suspended for refusing to submit to an alcohol or drug test? Yes No
f) Have you had a drug test with a result other than negative within the last 10-years? Yes No
3. 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. 710(g), 46 U.S.C. 7302(c), and 46 U.S.C. 7505.
Section IV: Mariner's Consent/Certification
1. 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 or 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 No thanks, I do not wish to participate at this time
2. 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.
Phone Number
4d. Act on my behalf in all matters pertaining to the processing of my
current USCG credential application.
5. Certification
My signature below attests that:
All information on this application is true and correct to the best of my knowledge.
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.
If registered as a U.S. Registered Pilot, I will obey all application regulations of the Secretary of Homeland Security, the U.S. Coast Guard and of any
other Federal Agency; and that I will be continuously available for service when required on those waters of the Great Lakes for which registered.
I consent to a check of the National Driver Registry related to my driving history, including motor vehicle convictions involving alcohol or controlled
substances; and any traffic violations in connection with a fatal traffic accident, reckless driving or racing.
I understand that by checking boxes 4a - 4d in Section IV, I authorize release of information to the third party indicated until issuance of a MMC or until
Agency final action is made.
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.
CG-719B (01/14) Page 5 of 6 Reset
DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 01/31/2016
APPLICATION FOR MERCHANT MARINER CREDENTIAL (MMC)
Section IV: Mariner's Consent/Certification (continued)
6. Applicant's Signature
x
Signature of an individual authorized to administer the Oath Date (MM/DD/YYYY)
Authority: 5 U.S.C. 301; 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7305, 7313, 7314, 7316, 7317, 7319, 7502, 7701, 8701, 8703, 9102; 46 C.F.R. 12.02; 49
C.F.R. 1.45, 1.46
Purpose: The principal purpose for which this information will be used is to determine domestic and international qualifications for the issuance of merchant
mariner credentials. This includes establishing eligibility of a merchant mariner's credential, duplicate credentials, or additional endorsements issued by the
Coast Guard and establishing and maintaining continuous records of the person's documentation transactions.
Routine Uses: The information will be used by authorized Coast Guard personnel with a need to know the information to determine whether an applicant is a
safe and suitable person who is capable of performing the duties of the Merchant Mariner. 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 non-issuance of
the requested credential.
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 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.