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Cg 719k Form: What You Should Know

S. Citizen, enter the SSN with which your application will be approved if you receive your Coast Guard authorization. IF YOU ARE NOT A U.S. CITIZEN, YOU MUST ENTER your SSN. IF YOU ARE NOT A U.S. CITIZEN, YOU MUST ENTER your SSN. CITIZENSHIP NOT RECORDED BY THE SECRETARY; OR IF YOU ARE NOT A U.S. CITIZEN AND YOU ARE NOT RECORDED AS CITIZEN OF THE COUNTRY IN WHICH YOU WILL PERSEVERE COMPARE, IN COMBINATION WITH YOUR STATE of Residence, AN APPLICATION FOR A TRIPLE MARINE MEDICALCYCLE REQUIREMENT UNDER 49 U.S.C. 30103(3) 1. Name on the Application. 2. Date of Birth. 3. If the applicant's age is in question, indicate your age by using the year your birthday falls. 4. If the applicant's name is the same as another applicant's name, include the name(s) of this applicant. 5. If the applicant is married, specify spouse's name(s). 6. If either the applicant or the spouse have renounced U.S. citizenship, indicate renunciation(s) by specifying date(s) of renunciation. 7. If both the applicant and the spouse have renounced U.S. citizenship, indicate date(s) at which renunciation is effective. If applicant is an alien and spouse naturalized, indicate date of birth. 8. If the applicant qualifies for a medical certificate, indicate the medical certificate(s) you have and their dates of issuance. 9. If the applicant is a member of your immediate family, provide name(s) of each member of the applicant's immediate family. 10. If the applicant is a permanent national who meets the criteria for the position(s) for which he/she is applying under this application and has passed the examination, verify the applicant's identity and complete the medical certificate, if required. 11. For members of this applicant's immediate family other than a spouse, do not list the spouses here. 12. For officers and members of this applicant's immediate family who are not a spouse, only indicate the applicant's spouse's name. 13. Name and address of each officer and member of the applicant's immediate family who is a spouse.

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