Form Cg-719k - Medical Evaluation Report Page 9
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9Page 9 of 9 of CG-719K Rev. 01-09
Section IX – Verifying Medical Practitioner Recommendation
Not Recommended Competent (explain in
Recommended
Needing Further Review
Competent
comments)
(explain in comments)
Comments on
Recommendation:
Verifying Medical Practitioner:
This signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the verifying
medical practitioner is true and correct to the best of his/her knowledge and that the verifying medical practitioner has not
knowingly omitted or falsified any material information relevant to this form.
Name (Printed):
Signature:
Date:
License Number:
Office Address, City, State, Zip Code:
Office Telephone:
U. S. Dept. of Homeland Security, USCG, CG 719K, Rev. 01-09
Applicant Name:
Date of Birth:
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