How to fill out the Captain’s License Medical Certificate Form

Fill out the applicant information section of the Application for Merchant Mariner Medical Certificate Form CG-719K by supplying your last name, first name, middle name, suffix, reference number, gender and date of birth. The second part of section I is where you supply your contact information, address, phone number, and email address. You can indicate the best methods of contacting you by checking the boxes near the appropriate fields. Be sure to write your full name (last, first, middle) and date at the bottom of each page of the form.

Sections II (a) and III of the Application for Merchant Mariner Medical Certificate Form CG-719K are to be completed by the applicant and reviewed by the medical practitioner. Read over section II (a) and check the yes or no box for each condition. For each of the condition(s) which you check yes, your medical practitioner must identify the item number, the condition/diagnosis, date of onset or diagnosis, any treatment required or received, the current status of the condition, and any limitation due to the condition in the space provided in section II (b).

Section III is where applicants 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. Additionally, you must report all non-prescription medications – including dietary supplements and vitamins – that were used for a period of 30 days or more within the last 90 days prior to the date the applicant signs the form CG719K. The information reported by the applicant must be verified by a medical practitioner. Be sure to write your full name (last, first, middle) and date at the bottom of each page of the form.

Section IV – IX of the Application for Merchant Mariner Medical Certificate Form CG-719K are to be completed by the medical practitioner. In Section X the applicant must sign and date the forms to attest 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 relative to this form.” Be sure to write your full name (last, first, middle) and date at the bottom of each page of the form.