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DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 01/31/2016
DISCLOSURE STATEMENT FOR NARCOTICS, DWI/DUI, AND/OR OTHER CONVICTIONS
------ Instructions ------
Who should submit this form?
Original Merchant Mariner Credential (MMC) applicants are required to list all convictions including military court martial, driving related convictions other than
minor traffic violations, and foreign court convictions. For renewals and endorsements, list all of those convictions not previously reported to the Coast Guard
on a MMC application. If you are unsure what you previously reported, you are encouraged to provide a complete list of all convictions. Failure to report
convictions will delay your credential and may result in denial. You may use this form or its equivalent to report your convictions, and may use additional pages
CONVICTION DEFINED (46 CFR 10.107)
A. An applicant will be considered to have received a conviction of a criminal Felony, Misdemeanor or a National Driver Register (NDR) offense if he or
1. Plead Guilty,
2. Plead No Contest,
3. Is granted Deferred Adjudication,
4. Is Required to:
(a) Attend Classes,
(b) Make contributions of Time or Money,
(c) Receive Treatment,
(d) Submit to any manner of Probation or Supervision, or,
(e) Forego Appeal of a trial court's conviction.
B. A conviction of more than one offense at a single trial will be considered to be multiple convictions.
C. Expunged convictions must be reported unless the expungement was based upon a showing that the court's earlier conviction was in error.
Section I: Personal Data
Legal Name - Enter complete legal name and include aliases used and/or maiden name(s).
• Reference Number - If you have been credentialed by the Coast Guard in the past, enter your reference number.
• Social Security Number - If you are applying for an original credential, enter your SSN.
• 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 guardian, authorizing the Coast Guard to issue a Medical Certificate.
Section II: Conviction and/or Drug Use Disclosure
Convicted of - Enter the exact charge(s) for which you were convicted.
• City - Enter the city/town/parish where you were convicted.
• State/Country - Enter the state/country where you were convicted.
• Date - Enter the date of conviction.
• Court findings - Enter the court's final determination of charges to include amended or added charges.
• Court sentence/requirements - Enter length of an incarceration ordered by court, probation (probation officer name and phone number), fines, classes,
driving privilege suspended/revoked and reinstatement date, etc.)
• What happened - Provide brief description of events leading to arrest to include the Arresting Agency.
Section III: Acknowledgement and Certification
Signature of Applicant - Acknowledge that you have read and understand the definition of conviction and certify that the information on this Disclosure
Statement for Narcotics, DWI/DUI, and/or other Convictions form is true and correct.
• Date - Enter current date.
PRIVACY ACT STATEMENT
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. 10.211
(a), 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 completing this form is 10 minutes. You may submit any comment concerning the
accuracy of this burden estimate or any suggestions for reducing the burden to the National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404.