How to fill out your Captain’s License Conviction Statement Form

Not everyone applying for a captain’s license will need a disclosure statements on form CG-719C. Applicants that answer yes to any of the questions a – f, asked in section III of the application form CG-719B, need to submit this form with their USCG application packet. Section I asks for personal data, you must fill in your last name, first name, middle name, alias or maiden name, reference number, social security number, and date of birth. Section II is conviction and/or drug use disclosure. To disclose your conviction fill in the following boxes under “conviction 1,” convicted of, city, state/country, date, court findings, court sentence/requirements, what happened and did you comply with/are you in compliance with court order. Section III lets you acknowledge and certificate the form by signing and dating it.