Cg 719S Form PDF Details

Navigating the process of obtaining or renewing credentials for maritime personnel requires attention to detail and an understanding of the necessary documentation, such as the CG-719S form, issued by the Department of Homeland Security's U.S. Coast Guard. This form, specifically designed for individuals serving on vessels under 200 Gross Register Tons, plays a crucial role in documenting and verifying sea service. To successfully complete the CG-719S, applicants must provide detailed information including personal identification, vessel specifics, and a comprehensive record of their service at sea. The form calls for the inclusion of various types of propulsion, the roles served on the vessel, and the geographic locations where the service took place. Furthermore, it requires a detailed account of the days spent underway each month, alongside specifics such as the average hours per day at sea and distances from shore. Section III emphasizes the importance of accuracy and honesty, outlining the legal implications of falsifying information. This mandatory verification process, supported by either written attestations from vessel owners or official documentation for non-owners, ensures the authenticity of the applicant's sea service claims. Utilizing this form not only aids mariners in achieving the credentials needed to operate vessels but also upholds the standards of safety and competence expected within the maritime industry.

QuestionAnswer
Form NameCg 719S Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform cg 719s, uscg form, small vessel sea service form, us coast gaurd sea service forms

Form Preview Example

 

 

 

 

 

 

 

 

DEPARTMENT OF HOMELAND SECURITY

 

 

OMB No. 1625-0040

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Coast Guard

 

 

 

 

 

 

 

 

 

Exp. Date: 03/31/2021

 

 

 

 

 

 

 

SMALL VESSEL SEA SERVICE FORM (OPTIONAL CG-719S)

 

 

 

 

 

 

 

 

 

 

 

 

For Service on Vessels of Less Than 200 Gross Register Tons Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section I: Applicant Information (Note: Complete One Form Per Vessel)

 

 

 

 

 

 

 

 

 

 

 

Name Last

 

First

 

 

 

 

Middle

 

 

 

Reference Number (if applicable)

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vessel Name

 

 

 

 

 

 

 

 

 

 

 

 

Official number(s) listed on the registration, certificate, or document

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Length

 

 

 

 

 

 

Width (if known)

 

Depth (if known)

 

 

Vessel Gross Tons

 

 

 

Feet

 

 

Inches

Feet

 

 

Inches

 

Feet

 

 

 

 

Inches

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Propulsion (Motor/Steam/Gas Turbine/Sail/Aux Sail)

 

 

 

 

 

 

 

Served As (Master/Mate/Operator/Deckhand/Engine etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Body or Bodies of Water Upon Which Vessel was Underway (Geographic Locations)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section II: Record of Underway Service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In the block under the appropriate month, write in the number of days you served for that year (you can show more than one year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

January

 

 

 

 

 

February

 

 

 

March

 

 

 

 

 

April

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

 

Days

 

 

 

Year

 

 

 

 

Days

 

Year

 

 

 

 

Days

Year

 

Days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

May

 

June

July

 

 

August

 

 

 

 

 

 

 

 

 

 

 

 

Year

 

Days

Year

 

Days

Year

 

Days

Year

 

Days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

September

 

October

 

November

 

 

December

 

 

 

 

 

 

 

 

 

 

 

 

Year

 

Days

Year

 

Days

Year

 

Days

Year

 

Days

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total number of days served on this vessel:

Average hours underway (per day)?

Average distance offshore:

Number of days served on Great Lakes:

Number of days served on waters shoreward of the boundary line as defined in 46 CFR Part 7:

Number of days served on waters seaward of the boundary line as defined in 46 CFR Part 7:

CG-719S (04/17)

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SMALL VESSEL SEA SERVICE FORM (OPTIONAL CG-719S)

Section III: Signature and Verification - Applicant Read Before Signing!

Owners of vessels may attest to their own experience and provide proof of ownership per 46 CFR 10.232.

Those who do not own their own vessel must obtain letters or other evidence from licensed personnel or the owners of the vessels listed per 46 CFR 10.232.

I certify that I have served on the above vessel as stated. I am making this statement in order that I, the applicant, may obtain a credential to operate a vessel under the provisions of Title 46 CFR, as applicable. I understand that if I make any false or fraudulent statement in this certification of service, I may be subject to a fine or imprisonment of up to five (5) years or both (18 U.S.C. 1001).

Signature of Applicant

Date (MM/DD/YYYY)

 

x

Owner, Operator or Master Read Before Signing! I certify that the above individual has served on the above vessel as stated. I am making this statement in order that the applicant may obtain a credential to operate a vessel under the provisions of Title 46 CFR, as applicable. I understand that if I make any false or fraudulent statement in this certification of service, I may be subject to a fine or imprisonment of up to five (5) years or both (18 U.S.C. 1001).

Signature and Title of Person Attesting to Experience

Date (MM/DD/YYYY)

 

x

Owner's, Operator's, or Master's Name

Last

First

Middle

 

 

 

 

 

 

 

 

 

 

 

 

Email Address (Optional)

Owner's, Operator's, or Master's address and phone number

Street Address

City

State Zip Code

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIVACY NOTICE

Authority: 14 U.S.C. 632; 46 U.S.C. 2103, 7101, 7302, 7502, 46 C.F.R. 10.301

Purpose: The information is collected by the Coast Guard to determine whether an applicant meets the regulatory standards for issuance of a U.S. Merchant Mariner Credential (MMC). The Coast Guard evaluates an applicant's qualifications to determine compliance with the national and international requirements for issuance of the MMC, any endorsement within the MMC, and medical certificate.

Routine Uses: The information is used by authorized Coast Guard personnel who have a need for the record to determine whether an applicant is a safe and suitable person and qualifies for the MMC, any endorsement within the MMC, and medical certificate. In addition, the Coast Guard uses this information to maintain and update records of merchant mariner documentation transactions. 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 the non-issuance of the MMC, any endorsement within the MMC, and medical certificate.

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 report is 15 minutes. You may submit any comments concerning the accuracy of this burden estimate or any suggestions for reducing the burden to: Chief, Office of Merchant Mariner Credentialing, 2703 Martin Luther King, Jr. Ave, S.E., STOP 7509, Washington, D.C., 20593-7509 or Office of Management and Budget, Paperwork Reduction Project (1625-0040), Washington, DC 20503.

CG-719S (04/17)

Page 2 of 2

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