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CG-719K (01/14) Previous Editions Obsolete
DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 01/31/2016
APPLICATION FOR MERCHANT MARINER MEDICAL CERTIFICATE
------ Instructions ------
Who must submit this form?
Applicants seeking a Medical Certificate are required to complete this form and submit it to the U.S. Coast Guard. Applicants seeking a raise-in-grade are
required to submit this form if a previous medical evaluation report has not been submitted within the last 3 years. Guidance for required submission of this form
can be found at the National Maritime Center website (http://www.uscg.mil/nmc/medical/default.asp).
The Coast Guard requires a physical examination and certification be completed to ensure that mariners:
• Are of sound health.
• Have no physical limitations that would hinder or prevent performance of duties (see below).
• Are free from any medical conditions that pose a risk of sudden incapacitation, which would affect operating, or working on vessels.
Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner
•
Legal Name - Enter complete legal name.
• 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.
• Reference Number - If you have been credentialed by the Coast Guard in the past, enter your reference number.
• Gender - Enter your legal gender.
• Home Address - Principle place of residence. PO Box is not acceptable.
• Delivery/Mailing Address - The address to which you want all correspondence and issued certificates sent. If blank, correspondence and credentials will be
sent to the Home Address.
• Primary Phone Number - Provide a primary phone number.
• Alternate Phone Number - Provide an alternate phone number (optional).
• E-mail Address - The National Maritime Center (NMC) may attempt to contact you via e-mail. You will receive automated updates regarding the status of
your application (optional).
• Other - Please provide additional means of communicating with you (satellite phone, work phone, etc.) (optional).
• Application Type - Self-explanatory.
Section II (a)(b): Medical Conditions - To be completed by the Applicant and reviewed by the Medical Practitioner
Conditions 1 - 34 - Applicants must report their relevant medical conditions to the best of their knowledge, and the Medical Practitioner must verify the
medical conditions. Check "YES" if the applicant has had a previous diagnosis or treatment of the condition by a health care provider, or if the applicant is
currently under treatment or observation for the condition, or if the condition is present regardless of treatment. If the Medical Practitioner, or any other health
care provider to the satisfaction of the medical practitioner, discovers a condition not reported by the applicant, he/she must check "YES" in the appropriate
block and explain in the comments.
Comments - The Medical Practitioner must address all reported conditions in this section. This detailed explanation should include, at a minimum,
identification of the condition, approximate date of diagnosis, any limitations, whether the condition is controlled, the prognosis, the treatment, and any
additional information as appropriate, referring to the evaluation data listed at the National Maritime Center (NMC) website http://www.uscg.mil/nmc/medical/
default.asp. Additional sheets may be added by the applicant and/or the medical practitioner if needed to complete this section of the form. Include applicant's
name and DOB on each additional sheet. Supporting medical documentation and testing for all identified conditions potentially requiring further review should
be submitted with each application as per the guidelines found on the NMC website http://www.uscg.mil/nmc/medical/default.asp. Detailed guidelines on
medical conditions subject to further review can be found on the NMC website. Medical practitioners should be familiar with the guidelines contained within this
document. Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials can be downloaded from the NMC website or by calling the NMC at
1-888-IASKNMC (1-888-427-5662).
Remove Instructions before submitting Application
Review by the Medical Practitioner - Verification of medications includes questioning the applicant about any medications or other substances reported,
reviewing relevant medical conditions to determine if the applicant has omitted any medications or other substances, and affirmatively reporting any omitted
current medications or other substances where required.
Section IV: (Vision) and V: (Hearing) - To be completed by the Medical Practitioner or other staff to the satisfaction of
the Medical Practitioner
The Medical Practitioner is not required to perform or witness every examination, test, or demonstration. These may be referred to other qualified practitioners
such as audiologists or optometrists; however, they must be reviewed to the satisfaction of the Medical Practitioner.
All examinations, tests and demonstrations must be performed, witnessed, or reviewed by a physician (Medical Doctor [MD], or Doctor of Osteopathy [DO]), or
nurse practitioner, or a certified physician assistant licensed by a state in the U.S., a U.S. possession, or a U.S. territory. The Medical Practitioner who
performs the examination must review Sections II and III of this form.
Section III: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner
CG-719K (01/14) Previous Editions Obsolete
Section VII: Demonstration of Physical Ability - To be completed by the Medical Practitioner
LISTS OF TASKS CONSIDERED NECESSARY FOR PERFORMING ORDINARY AND EMERGENCY RESPONSE SHIPBOARD FUNCTIONS
Shipboard Tasks, Function,
Event, or Condition
Related Physical Ability Acceptable Demonstration
Routine movement on slippery,
uneven, and unstable surfaces
Maintain balance (equilibrium)
Has no disturbance in sense of balance
Routine access between levels Climb up and down vertical ladders and stairways
Is able, without assistance, to climb up and down vertical
ladders and stairways
Routine movement between spaces
and compartments
Step over high doorsills and coamings, and move
through restricted accesses
Is able, without assistance, to step over a doorsill or coaming
of 24 inches (600 millimeters) in height. Able to move through
a restricted opening of 24 x 24 inches
Open and close watertight doors,
hand cranking systems, open/close
valve
Manipulate mechanical devices using manual and
digital dexterity, and strength
Is able, without assistance, to open and close watertight doors
that may weigh up to 55 pounds (25 kilograms); should be
able to move hands/arms to open and close valve wheels in
vertical and horizontal directions; rotate wrists to turn handles;
able to reach above shoulder height
Handle ship's stores Lift, pull, push, carry a load
Is able, without assistance, to lift at least a 40 pound (18.1
kilograms) load off the ground, and to carry, push, or pull the
same load
General vessel maintenance
Crouch (lowering height by bending knees); kneel
(placing knees on ground); stoop (lowering height by
bending at the waist); use hand tools such as span-
ners, valve wrenches, hammers, screwdrivers, pliers
Is able, without assistance, to grasp, lift, and manipulate
various common shipboard tools
Emergency response procedures
including escape from smoke-filled
spaces
Crawl (ability to move body using hands and knees);
feel (ability to handle or touch to examine or determine
differences in texture and temperature)
Is able, without assistance, to crouch, kneel, and crawl, and to
distinguish differences in texture and temperature by feel
Stand a routine watch Stand a routine watch
Is able, without assistance, to intermittently stand on feet for
up to four hours with minimal rest periods
React to visual alarms and
instructions, emergency response
procedures
Distinguish an object or shape at a certain distance
Fulfills the eyesight standards for the merchant mariner
credential applied for (see www.uscg.mil/nmc for more info)
React to audible alarms and
instructions, emergency response
procedures
Hear a specified decibel (dB) sound at a specified
frequency
Fulfills the hearing standards for the merchant mariner
credential applied for
Make verbal reports or call attention
to suspicious or emergency
conditions
Describe immediate surroundings and activities, and
pronounce words clearly
Is capable of normal conversation
Participate in fire fighting activities
Be able to carry and handle fire hoses and fire
extinguishers
Is able, without assistance, to pull an uncharged 1.5 inch
diameter, 50' fire hose with nozzle to full extension, and to lift
a charged 1.5 inch diameter fire hose to fire fighting position
Abandon ship Use survival equipment
Has the agility, strength, and range of motion to put on a
personal flotation device and exposure suit without assistance
from another individual
Section VIII: Food Handler Certification - To be completed by the Medical Practitioner
The Medical Practitioner shall complete Section VIII for all applicants requiring Food Handler Certification. The Medical Practitioner need not perform any
additional laboratory testing unless it is deemed clinically necessary. Applicants and currently employed food workers should report information about their
health as it relates to diseases that are transmissible through food. The following issues should be considered by the Medical Practitioner when certifying an
applicant:
a. The applicant reports they have been diagnosed with an illness due to organisms such as Salmonella Typhi, Shigella spp., Shiga-toxin-producing
Escherichia coli, Hepatitis A virus, etc.
b. The applicant reports they have at least one symptom caused by illness, infection, or other source that is associated with an acute gastrointestinal illness
such as diarrhea, fever, vomiting, jaundice, or sore throat with fever.
c. The applicant reports they have a lesion containing pus, such as a boil or infected wound, which is open or draining and is on hands or wrists or on
exposed portions of the arms.
d. The applicant reports they have had Salmonella Typhi within the past three months, Shigella spp. within the past month, Shiga-toxin-producing Escherichia
coli within the past month, or Hepatitis A virus ever.
e. The applicant reports they are suspected of causing or being exposed to a confirmed disease outbreak caused by organisms such as Salmonella Typhi,
Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc. This would include outbreaks associated with events such as a family meal,
church supper, or festival because the employee ate food implicated in the outbreak, or ate food at the event prepared by a person who is infected or who
is suspected of being a shedder of the infectious agent.
f. The applicant reports they live in the same household as, and have knowledge about, a person who is diagnosed with organisms such as Salmonella
Typhi, Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc.
g. The applicant reports they live in the same household as, and have knowledge about, a person who attends or works in a setting where there is a
confirmed disease outbreak caused by organisms such as Salmonella Typhi, Shigella spp., Shiga-toxin-producing Escherichia coli, Hepatitis A virus, etc.
Section VI: Physical Examination - Items 1-17; To be completed by the Medical Practitioner
Self-explanatory
CG-719K (01/14) Previous Editions Obsolete
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 this form is 18 minutes. You may submit any comments concerning the accuracy of this
burden or any suggestions for reducing the burden to the National Maritime Center, 100 Forbes Drive, Martinsburg, WV 25404.
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. 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.
Section IX: Summary - To be completed by the Medical Practitioner
PRIVACY ACT STATEMENT
Proof of Identity
a. Applicants shall present acceptable proof of identity to the Medical Practitioner conducting examinations.
b. Proof of identity shall consist of one current form of valid government issued photo identification.
c. The following credentials are examples of acceptable proof of identity: Unexpired official identification issued by a Federal, State, or local government or by a
territory or possession of the United States, such as a passport, U.S. driver's license, U.S. military ID card, Merchant Mariner's Document/Merchant Mariner
Credential, or Transportation Worker Identification Credential.
Overall fitness recommendation: The Medical Practitioner must ensure a complete history and physical are conducted and make recommendations as to
the fitness of the applicant. Final approval of the mariner's status rests with the U.S. Coast Guard.
Medical Practitioner: Certification that the general medical examination, vision and hearing tests, as well as the physical demonstration of competence as
appropriate, have been performed to the satisfaction of the Medical Practitioner. The Medical Practitioner must sign and date the certification where
indicated. This signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the medical practitioner is true and
correct to the best of his/her knowledge and that the medical practitioner has not knowingly omitted or falsified any material information relevant to this form.
Section X: Application Certification - To be completed by the Applicant
Self-explanatory
Page 1 of 5
CG-719K (01/14)
Previous Editions Obsolete
Applicant Name: (Last, First, MI.)
Date of Birth: (MM/DD/YYYY)
DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040
U.S. Coast Guard Exp. Date: 01/31/2016
APPLICATION FOR MERCHANT MARINER MEDICAL CERTIFICATE
Section I: Applicant Information - To be completed by the Applicant and reviewed by the Medical Practitioner
Last Name
First Name
Middle Name Suffix (Jr., Sr., III)
Reference Number (if applicable) Gender: Date of Birth (MM/DD/YYYY)
Section II(a): Medical Conditions - To be completed by the Applicant and reviewed by the Medical Practitioner
Please indicate best method(s) of contact by checking the appropriate box(es). Optional if information is same as most recent CG-719B.
Zip CodeStateCity
Street Address
Home Address (PO Box NOT acceptable)
Delivery/Mailing Address, if different (PO Box acceptable)
Zip CodeStateCity
Primary Phone Number
Alternate Phone Number
E-mail Address
Other
I have a medical waiver:
No
Yes
FemaleMale
If YES, provide a copy of the medical waiver to the Medical Practitioner.
No
Yes
1. Eye/vision problems except glasses
2. Ear/nose/throat problems or other ENT problems/surgery
3. High or low blood pressure
4. Heart or vascular disease of any kind
6. Lung disease of any type (asthma, bronchitis, emphysema, etc.)
8. Diabetes, glucose intolerance, or sugar in urine
9. Thyroid problem
10. Stomach, liver, or intestinal disorder
11. Kidney problems/stones or blood in urine
12. Any other urinary or bladder problems not listed above
13. Skin disorder or problem
15. Infectious/contagious disease
17. Epilepsy, fits, or seizures
18. Loss of consciousness or memory
7. Any blood disorder (anemia, hemophilia, blood clots,
polycythemia, etc.)
22. Stroke or Transient Ischemic Attack (TIA), brain tumor or
other brain disorder
5. Heart surgery and/or implanted devices (pacemaker,
defibrillator, etc.)
14. Allergies or allergic reactions to any substance, medication,
or food.
16. Any sleep problems: obstructive sleep apnea, restless leg
syndrome, narcolepsy, shift work sleep disorder, insomnia, etc.
20. Dizziness/fainting spells/balance problems
21. Frequent motion sickness requiring medication
23. Any neurologic disorder or nerve problems including
numbness and/or paralysis, not listed above
24. Attention deficit disorder with or without hyperactivity
25. Anxiety, depression, bipolar disorder, adjustment
disorder, PTSD, or schizophrenia
26. Suicide attempt or thought (ideation) of suicide
27. Evaluation, treatment, or hospitalization for alcohol or
substance use, abuse, addiction, or dependence (including
illegal drugs, prescription medications, or other substances)
28. Any other psychiatric disorder, mental health evaluation/
hospitalization
29. Back pain, joint problems, or orthopedic surgery
30. Amputation, prosthesis, or use of ambulatory devices
(cane, walker, braces, etc.)
31. Fractures, recurrent dislocations or limitation of motion of
any joint
32. Have you ever been signed off as sick or repatriated for
medical reasons within the last six years?
33. Any diseases, surgeries, cancers, illnesses, or
disabilities not listed on this form?
34. Any hospital admissions within the last six years not
listed elsewhere in this Section?
Yes
No
Yes
No
Yes
No
19. Frequent or severe headaches
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
To the best of your knowledge, have you ever had, required treatment for, or do you presently have any of the following conditions?
Application Type:
First Class Pilot
Medical Certificate
Street Address
Reset
Page 2 of 5
CG-719K (01/14)
Previous Editions Obsolete
Applicant Name: (Last, First, MI.)
Date of Birth: (MM/DD/YYYY)
Section II(b): Medical Conditions - To be completed by the Medical Practitioner
Instructions: For each "YES" answer, identify the item numbers, the condition/diagnosis, date of onset or diagnosis, any treatment required or received, the
current status of the condition, and any limitations due to the condition. As applicable, attach supporting documentation to verify findings. Additional sheets may
be added as needed being sure applicant name and date of birth appear on each additional sheet.
Section III: Medications - To be completed by the Applicant and reviewed by the Medical Practitioner
Applicants who are required to complete a general medical exam are required to report all prescription medications prescribed, filled or refilled, and/or taken
within 30 days prior to the date that the applicant signs the CG-719K. In addition, all prescription medications, and all non-prescription (over-the-counter)
medications including dietary supplements and vitamins, that were used for a period of 30 or more days within the last 90 days prior to the date that the
applicant signs the CG-719K or approved equivalent form, must also be reported.
The information reported by the applicant must be verified by the verifying medical practitioner or other qualified medical practitioner to the satisfaction of the
verifying medical practitioner to include the following two items: (1) Report all medications (prescription and non-prescription), dietary supplements, and
vitamins. (2) Include dosages of every substance reported on this form, as well as the condition for which each substance is taken.
Additional sheets may be added by the applicant and/or medical practitioner if needed to complete this section (include applicant name and date of birth on
each additional sheet).
Applicant (Please Print) Medical Practitioner (Please Print)
Number Additional Information (Please Print)
If none, check "NONE"
NONE
Reset
Page 3 of 5
CG-719K (01/14)
Previous Editions Obsolete
Applicant Name: (Last, First, MI.)
Date of Birth: (MM/DD/YYYY)
REPORT OF MEDICAL EXAMINATION
Sections IV and V should be completed by the Medical Practitioner or other medical staff to the satisfaction of the Medical Practitioner.
Section IV: Vision
The Medical Practitioner must indicate test used and results (number of errors). Additional information must be reported in Section VII. Color sensing
lenses (e.g. X-Chrome) are prohibited.
a. Visual Acuity
b. Color Vision (check one) The following color sense testing methodologies are acceptable
Section V: Hearing
An applicant with normal hearing by forced whispered voice > 5 feet with or without hearing aids does not need to complete either the audiometer test or the
functional speech discrimination test.
(a) If hearing is abnormal, then perform either a functional speech discrimination test at 65dB or an audiogram documenting thresholds and averages as
indicated below. Both aided and unaided values should be recorded for applicants requiring hearing aids.
(b) All applicants with an unaided threshold > 30dB in the better ear should have functional speech discrimination testing performed at 65dB.
(c) Refer to Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials from the NMC website (http://www.uscg.mil/nmc/medical/default.asp)
for further guidance. Report any additional information or comments in Section VII.
Distant Uncorrected
Right: 20/
Left: 20/
If Necessary, Distant Corrected To
Right: 20/
Left: 20/
Field of Vision
This applicant must have a 100-degree horizontal field of vision.
AOC (1965) - (6 or fewer errors on plates 1-15)
AOC-HRR (2nd Edition) - (No errors in test plates 7-11)
HRR PIP (4th Edition) - (No errors in test plates 5-10)
Richmond (2nd and 4th Edition) - (6 or fewer errors)
Titmus Vision Tester/OPTEC 2000 - (No errors on 6 plates)
OPTEC 900 (colored lights) Test per instruction booklet
Farnsworth D-15 Hue Test (attach test results)
(Engineer/radio officer/tankerman/MODU only)
Ishihara pseudoisochromatic plates test, 14 plate (5 or less errors)
Ishihara pseudoisochromatic plates test, 24 plate (6 or less errors)
Ishihara pseudoisochromatic plates test, 38 plate (8 or less errors)
Farnsworth Lantern (colored lights) Test per instruction booklet
Dvorine pseudoisochromatic 15 plate test (6 or less errors)
An alternative test approved by the Coast Guard (Indicate test)
Passed Failed
Color Vision Testing Results:
Number of Errors:
If color vision test is failed, can the Applicant
distinguish red, green, blue, and yellow:
Yes
No
Normal Hearing Abnormal Hearing Hearing Aid Required
500Hz 1,000Hz 2,000Hz 3,000Hz Average
Right Ear (Unaided)
Left Ear (Unaided)
Right Ear (Aided)
Left Ear (Aided)
Audiometer
Threshold Value
Functional Speech
Discrimination Test @ 65dB, if required by
instruction (b) above
Right Ear (Unaided):
Left Ear (Unaided):
Right Ear (Aided):
Left Ear (Aided):
Normal
Abnormal
%
%
%
%
Reset
Page 4 of 5
CG-719K (01/14)
Previous Editions Obsolete
Applicant Name: (Last, First, MI.)
Date of Birth: (MM/DD/YYYY)
Section VI: Physical Examination - Items 1-17 of this section must be completed by the Medical Practitioner.
Height (inches only):
Pulse Resting:
Weight (lbs):
Initial Blood Pressure:
Body Mass Index (BMI):
(For BMI > 40 refer to Section VII)
Repeat Blood Pressure
(if needed):
Please make comments in the space provided on any item indicated as an "abnormal" system/organ.
Normal
Abnormal
1. Head, Face, Neck, Scalp
Normal
Abnormal
2. Eyes/Pupils/EOM
Normal
Abnormal
3. Mouth and Throat
Normal
Abnormal
4. Ears/Drums
Normal
Abnormal
5. Lungs and Chest
Normal
Abnormal
6. Heart
Normal
Abnormal
7. Abdomen
Normal
Abnormal
8. Upper/Lower Extremities
Normal
Abnormal
9. Spine/Musculoskeletal
Normal
Abnormal
10. Skin
Normal
Abnormal
11. Lymphatic
Normal
Abnormal
12. Neurologic
Normal
Abnormal
13. Vascular System
Normal
Abnormal
14. Genitourinary System
Normal
Abnormal
15. General/Systemic
Yes
No
16. Hernia
17. Missing Extremities/Digit
Additional Medical Comments
Item Additional Information (Please Print)
Yes
No
Reset
Page 5 of 5
CG-719K (01/14)
Previous Editions Obsolete
Applicant Name: (Last, First, MI.)
Date of Birth: (MM/DD/YYYY)
Section VII: Demonstration of Physical Ability - To be completed by the Medical Practitioner
1. The Medical Practitioner shall require that the applicant demonstrate the ability to meet the guidelines contained within Section VII of the CG-719K
instructions. This does not mean, for example, that the applicant must actually don an exposure suit, pull an unchanged 1.5 inch diameter 50' fire hose with
nozzle to full extension, or lift a charged 1.5 inch diameter fire hose to firefighting position. Rather, the Medical Practitioner may utilize alternative measures
to satisfy himself or herself that the applicant possesses the ability to meet the guidelines in the third column. A description of the methods utilized by the
medical practitioner should be reported in the Comments section provided below.
2. All practical demonstrations should be performed by the applicant without assistance. Any prosthesis normally worn by the applicant, and any other aid
devices, may be used by the applicant in all practical demonstrations except when the use of such items would prevent the proper wearing of mandated
personal protection equipment (PPE).
3. If the Medical Practitioner is unable to conduct the practical demonstration, the applicant should be referred to a competent evaluator of physical ability. The
Coast Guard recognizes that all medical practitioners may not have the equipment necessary to test all of the tasks as listed. Equivalent alternate testing
methodologies may be used. For further information, check the Medical and Physical Evaluation Guidelines for Merchant Mariner Credentials (http://www.
uscg.mil/nmc/medical/default.asp).
4. If the applicant is unable to perform any of the following functions, the Medical Practitioner should provide information on the degree or the severity of the
applicant's inability to meet the standards. The results of any practical demonstration or attendant physical evaluation should be recorded in the Comments
section provided below.
Applicant has the physical strength, agility, and flexibility to
perform all of the items listed in the instruction table.
Applicant does NOT have the physical strength, agility, and
flexibility to perform all of the items listed in the instruction
table.
Physical Ability Results COMMENTS: (Please Print)
Section VIII: Food Handler Certification - To be completed by the Medical Practitioner
If Food Handler Certificate is sought by the applicant, is applicant free from communicable disease:
Yes
No
Section IX: Summary - To be completed by the Medical Practitioner
No
Yes
Applicant proof of identity provided:
Overall fitness recommendation:
Fit for Duty
Not Fit for Duty Needs Further Review
Comments:(Please Print)
Medical Practitioner:
My signature attests, subject to criminal prosecution under 18 USC § 1001, that all information reported by the medical practitioner is true and correct to the
best of his/her knowledge and that the medical practitioner has not knowingly omitted or falsified any material information relevant to this form. My signature
also attests that I have fully evaluated all examination tests and results submitted in support of this application.
Zip CodeStateCity
Office Street Address
M.I.First NameLast Name
Date (MM/DD/YYYY)Signature
MD/DO PA NP
Phone Number
License Number State
(Place office address stamp here)
Section X: Applicant Certification - To be completed by the Applicant
My signature below attests, subject to prosecution under 18 USC § 1001, that all information provided by me on this form is complete and true to the best of
my knowledge, and I agree that it is to be considered part of the basis for issuance of any medical certificate to me. I have not knowingly omitted any
material information relevant to this form. I have also read and understand the Privacy Act Statement that accompanies this form.
Signature of Applicant Date (MM/DD/YYYY)
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