Form Cg-719k - Medical Evaluation Report Page 3
Download a blank fillable Form Cg-719k - Medical Evaluation Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cg-719k - Medical Evaluation Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9Page 3 of 9 of CG-719K Rev. 01-09
Section I - Applicant Information
Last Name:
First Name:
Middle Name:
Suffix: (Jr., Sr., III)
Age:
Date of Birth (MM/DD/YYYY):
Social Security Number:
Applicant Certification (to be signed by applicant)
My signature below attests, subject to prosecution under 18 USC 1001, that all information that I have reported is true
and correct to the best of my knowledge, and that I have not knowingly omitted to report any material information
relevant to this form.
Date:
Printed Name:
Signature:
How do you wish to be contacted? (phone, e-mail, letter, fax)
Please include contact information below:
Section II – Release
I hereby authorize the verifying medical practitioner (VMP), who has signed the certification on page 9 of this form, to
release to, or discuss with authorized Coast Guard personnel, any pertinent information in his/her possession
regarding any physical or medical condition that may require review by the Coast Guard prior to determining whether
the Coast Guard should issue a credential(s) for maritime service.
I understand that this authorization is voluntary. I also understand that failure to provide authorization could affect the
Coast Guard’s ability to make a timely determination as to whether the Coast Guard should issue me a credential(s)
for maritime service. This authorization will remain in effect until the Coast Guard determines whether to issue me the
requested credential(s) for maritime service, but no longer than one year.
I have read and understand the following statement about my rights:
► I may revoke this authorization at any time prior to its expiration date by notifying the verifying medical practitioner in
writing, but the revocation will not have any effect on any actions taken before they received the notification.
► Upon request, I may see or copy the information described in this release.
► I am not required to sign this release to receive my medical evaluation.
Applicant:
Name (Printed):
Signature:
Date:
Applicant Name: _______________________________________
Date of Birth:____________________________
Previous Edition Obsolete
Reset
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal