General Requirements For Licenses Checklist

GENERAL REQUIREMENTS FOR LICENSES NAME: DATE RECEIVED: CLERK INITIALS 1. 2. 3. 4. 5. 6. 7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

SOCIAL SECURITY #:

GENERAL REQUIREMENTS Reference 46 CFR; Policy Letter 04-02 CG-719B Application Complete Explanation if YES marked in Section III of Application CG-719B NDR Consent Signed on Application CG-719B NDR Requested: Date Requested: ___________ ❏ No Hit ❏ Hit ❏ Cleared Hit Criminal Record Check Results: Seaman Locator List Checked

EVAL INITIALS 1. 2. 3. 4.

REFERENCE

10.205(k)

5. 6.

MSM Vol. III, Ch. 1.G.2.a 10.202(d) 10.201(f) 10.202(h) 10.201(e)

Oath Administered (Original License only) AGE: • Minimum age 21 (see 46 CFR 10.201(f) and 10.202(h) for exceptions) CITIZENSHIP: • U.S. Citizenship: • Non-U.S. Citizenship (Aliens) (OUPV undocumented vessels only): Social Security Number (Original License only) Fingerprint Cards (2) (Original License only) First Aid Certificate (Original License only) CPR Certificate (Original License only) Character References (3) (Original License only) Physical Examination CG-719K (within 1 year for original; within 3 years for raise in grade) DOT/USCG Drug Test (within 6 months) or Enrollment in Drug Test Program Course Completion Certificate (list course certificates under Notes) Camera Set-Up Form (if getting new MMD) Recent Passport Photos (2) (for STCW certificate) User Fees: ❏ Eval ❏ Exam ❏ License Issue ❏ MMD Issue ❏ Other

7. 8. 9.

MSM Vol. III, Ch. 1.H.4 10.201(h) 10.205(h) 10.205(h) 10.205(f) 10.205(d)

10.

16.220

16. 17. 18. 19. 20.

11. 12. 13. 14. 15.

10.109

NOTES:

Evaluator’s Signature and Date

(Pending)

Evaluator’s Signature and Date

(Approved)

HIGHLIGHT IF APPLICABLE: Vision Waiver (Local) (HQ)

Physical Waiver (Local) (HQ)

OK TO ISSUE (Circle Credential(s) Being Issued): License

MMD MLD-FM-REC-103 (02)

STCW Rev. 3/2004