Form Cg-719c - Department Of Homeland Security - U.s. Coast Guard Disclosure Statement For Narcotics, Dwi/dui, And/or Other Convictions Page 2

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DEPARTMENT OF HOMELAND SECURITY
.
OMB No
1625-0040
U.S. Coast Guard
Exp. Date: xx/xx/xxxx
DISCLOSURE STATEMENT FOR NARCOTICS, DWI/DUI, AND/OR OTHER CONVICTIONS
Section I: Personal Data (Please Print)
.
1. Legal Name
Last
First
Middle
Alias(es) or Maiden Name(s) (if applicable)
2. Reference Number
3. Social Security Number (000-00-0000)
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.
5. Type of Drug
6. Month/Year of Last Use (MM/YYYY)
DANGEROUS DRUG
USE DETAILS (if any)
CONVICTION DETAILS
CONVICTION 1
a. Convicted of
b. City
c. State/Country
d. Date (MM/DD/YYYY)
e. Court findings: (deferred adjudication, guilty plea/no
f. Court sentence/requirements: (length of any incarceration ordered by
contest, etc.)
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
c. State/Country
d. Date (MM/DD/YYYY)
e. Court findings: (deferred adjudication, guilty plea/no
f. Court sentence/requirements: (length of any incarceration ordered by
contest, etc.)
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
Date (MM/DD/YYYY)
CG-719C (01/14)
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