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U.S. Coast Guard Form CG-719K, Application for Medical Certificate, page 1
Very Complex · 89/100Form Complexity Index

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What this form asks for

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CG-719K is the U.S. Coast Guard’s official application and medical evaluation form for issuing a Merchant Mariner Medical Certificate. It collects the mariner’s identifying information, medical conditions and medications, and the results of a physical exam, vision and hearing testing, and (when required) a demonstration of physical ability. A licensed medical practitioner must review and complete key sections and attest to the accuracy of the examination and findings. The Coast Guard uses the completed form to determine whether the applicant meets medical standards for safe maritime service and credentialing.
Fillable fields460
Pages10
Sections118
Tables and lists5
Questions that depend on earlier answers169
Form Complexity IndexVery Complex, 89/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Ensures all 10 pages of CG-719K are submitted (including instructions pages)

Validate that the submission includes all pages required by the Coast Guard (the form explicitly states all 10 pages must be submitted, including instructions). This prevents incomplete packets that cannot be processed or reviewed by the Medical Practitioner (MP) and NMC. If any page is missing, the application should be rejected as incomplete and the applicant prompted to resubmit the full packet.

Validates Applicant Legal Name completeness and format (Last, First, MI, Suffix)

Check that Last Name and First Name are present and contain only valid name characters (letters, spaces, hyphens, apostrophes), and that Middle Name/Initial and Suffix (if provided) follow expected formats. This is critical for identity matching across Coast Guard systems and for ensuring additional sheets can be correctly attributed to the applicant. If invalid or missing, flag the submission for correction before acceptance.

Validates Date of Birth format and age-related requirements

Ensure Date of Birth is provided and matches MM/DD/YYYY, represents a real calendar date, and is not in the future. If the applicant is under 18, require an attached notarized parent/guardian authorization as stated in the instructions. If DOB is invalid or the under-18 attachment is missing, the submission should fail validation and be returned for completion.

Requires Mariner Reference Number or SSN and validates its format

Enforce that either a Mariner Reference Number or a Social Security Number is provided, since the form states the Coast Guard will not accept an application without a reference number or MMC. If SSN is used, validate it is 9 digits (optionally formatted as XXX-XX-XXXX) and not an obviously invalid pattern (e.g., all zeros). If neither identifier is present or the identifier format is invalid, reject the application as non-acceptable.

Validates Sex selection is present and within allowed values

Confirm that Sex is selected and is one of the allowed options shown on the form (Male/Female). This supports consistent medical evaluation and record matching. If missing or outside allowed values, the submission should be flagged for correction.

Validates Home Address is a physical address (no PO Box) and is complete

Check that Home Address includes street address, city, state, and ZIP, and that the street address does not contain PO Box indicators (e.g., 'PO Box', 'P.O. Box'), as explicitly prohibited. This ensures the principal place of residence is captured correctly for official records. If a PO Box is detected or required components are missing, fail validation and request a corrected physical address.

And 10 more checks
  • Validates Delivery/Mailing Address logic and completeness (defaults to Home Address if blank)
  • Validates contact information: primary phone required; phone/email formats
  • Ensures at least one Endorsement Held or Sought is selected
  • Validates 'Other' endorsement explanation is provided when selected
  • Food Handler Certification dependency check (Section I vs Section II)
  • Medical Conditions Section III(a) completeness and single-response enforcement per item
  • Section III(b) required follow-up for every YES condition in III(a)
  • Medical Waiver (MW) attachment requirement and consistency
  • Medications section logic: 'Do you currently use any medication?' vs medication table completion
  • Medical Practitioner credentials and attestation completeness (Section IX.e)

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How to Fill Out CG-719K Online for Free in 2026

What the AI walks you through.

  1. Confirm you are applying for a Coast Guard Medical Certificate and gather prerequisites (Mariner Reference Number or MMC/SSN, government photo ID, and any relevant medical records/waivers).
  2. Complete Section I (Applicant Information), including contact details and selecting all applicable endorsements held or sought (e.g., Deck, Engine, STCW, Food Handler, Pilotage, entry-level).
  3. Fill out Section III(a) (Medical Conditions) by answering each condition Yes/No and marking Previously Reported (PR) and/or Medical Waiver (MW) where applicable; prepare supporting documentation for any “Yes” items.
  4. Complete Section IV (Medications) by listing all required prescription/nonprescription medications, supplements, and vitamins per the form’s lookback periods, including dose, frequency, and condition treated.
  5. Schedule an exam with an eligible Medical Practitioner (physician/PA/NP; MD required for U.S. Registered Pilots) and bring your completed sections, photo ID, and supporting records for the practitioner to review and complete Sections II and V–IX (food handler certification if applicable, physical exam, vision, hearing, physical ability if required, and summary).
  6. Review the completed application for completeness (initials/dates where required, attachments noted, signatures present), then sign Section X (Applicant Certification) and optionally complete Section XI (Applicant Consent/third-party authorizations).
  7. Submit all 10 pages (including instructions) and any attachments to the U.S. Coast Guard/National Maritime Center as required, ensuring the application includes your reference number or MMC so it will be accepted.

Common Mistakes in Completing CG-719K

The ones the AI is built to catch.

Submitting fewer than all 10 pages (including instructions)
Applicants often upload only the signature pages or the exam pages and omit “instruction” pages because they assume they aren’t required. The CG-719K instructions explicitly state all 10 pages must be submitted, and missing pages commonly trigger a rejection or delay at the National Maritime Center. Avoid this by scanning and submitting the entire packet in order (pages 1–10), even if some pages are “N/A” for your situation.
Missing Mariner Reference Number/MMC requirement (or using the wrong identifier)
People frequently enter only a Social Security Number when they already have a Mariner Reference Number, or they leave the field blank entirely. The form states the Coast Guard will not accept an application without a reference number or an MMC, so this can cause an immediate non-acceptance. Use your Mariner Reference Number if you have ever held a Coast Guard credential; otherwise provide the SSN as allowed and ensure it matches your identity documents.
Using a PO Box for the Home Address
Applicants often put a PO Box in the Home Address because it’s their preferred mailing address, but the form clearly says PO Box is not acceptable for the Home Address (principal place of residence). This can lead to follow-up requests, processing delays, or returned correspondence if addresses don’t align. Enter a physical residential street address for Home Address, and use the Delivery/Mailing Address field for a PO Box if needed.
Not checking any endorsement boxes in Section I
A very common oversight is leaving “Endorsement Held or Sought” blank because applicants think it’s only for current credential holders. The form states that if nothing is selected, the Coast Guard will not accept the application, resulting in a preventable rejection. Check all that apply (e.g., Deck, STCW, Engine, Food Handler, Pilot, Entry-level with lookout duties) and add an explanation in “Other” when necessary.
Incorrect date formats or inconsistent dates (DOB, exam date, signatures)
Applicants and medical practitioners frequently mix formats (DD/MM vs MM/DD), omit leading zeros, or sign with a date that doesn’t match the exam date or medication reporting window. Inconsistent or unclear dates can trigger clarification requests and can undermine the 30/90-day medication reporting requirements tied to the applicant’s signature date. Always use MM/DD/YYYY everywhere, and ensure signature dates align logically with the exam and the medication history timeframe.
Underreporting medical conditions in Section III(a) (marking “No” when history exists)
People often answer “No” because a condition is controlled, “in the past,” or they think it’s not relevant (e.g., prior surgery, sleep apnea, mental health treatment, repatriation, or hospitalizations). The instructions require “Yes” if there was diagnosis/treatment, current observation, or the condition is present regardless of treatment, and omissions can lead to delays, requests for records, or potential enforcement issues due to the 18 USC § 1001 attestation. Avoid this by answering broadly and honestly, then letting the Medical Practitioner document status, limitations, and treatment in Section III(b).
Failing to complete Section III(b) details for every “Yes” item (or not attaching supporting documentation)
Even when applicants correctly check “Yes,” the follow-up narrative is often missing key elements like diagnosis date, current status, treatment, limitations, and whether documentation is attached. The form requires the Medical Practitioner to discuss each “Yes” item and to attach recommended evaluation data for conditions subject to further review, and missing details commonly result in “Needs Further Review” and additional evidence requests. Ensure each “Yes” item number is addressed in III(b) with dates and specifics, and check the “Attached” box when you include extra pages or test results.
Misusing PR (Previously Reported) and MW (Medical Waiver) checkboxes
Applicants frequently mark PR or MW incorrectly—either checking PR without having previously reported it to the Coast Guard, or checking MW without providing the waiver letter and required follow-up documentation. This creates confusion for reviewers and can delay processing while the Coast Guard verifies prior records or requests missing waiver materials. Only mark PR if it was previously reported to the Coast Guard, mark MW only if you have an active waiver, and provide a copy of the waiver letter plus any waiver reporting requirements.
Incomplete medication reporting (missing OTCs, supplements, dose/frequency, or timeframe)
Many applicants list only prescriptions and forget over-the-counter meds, vitamins, dietary supplements, or “as needed” drugs, and they often omit dose, frequency, or the condition being treated. The form requires reporting medications taken within 30 days before signing and those used 30+ days within the last 90 days, and incomplete lists can trigger follow-up or raise concerns if conditions imply medications that aren’t listed. Use the exact reporting windows, include all substances (Rx/OTC/supplements), and provide dose, frequency, and purpose; the Medical Practitioner should add duration and side effects in comments.
Vision and color vision testing recorded incorrectly or without required specifics
A common error is writing “passed” without documenting the test method, number of errors, or corrected vs uncorrected acuity, or allowing color-enhancing lenses despite the stated prohibition. Missing the test type and error count can invalidate the color vision section and lead to retesting requests. Ensure distance vision is recorded for each eye (uncorrected and correctable-to if applicable), select the exact color vision test used, and record the number of errors and pass/fail per the listed standards.
Hearing section not completed according to the decision rules (whisper test vs audiogram/speech discrimination)
Applicants and clinics often perform an audiogram but fail to record aided/unaided values, averages, or the functional speech discrimination test when thresholds require it, or they leave the “normal/abnormal/hearing aid required” selection unclear. The instructions specify when additional testing is required (e.g., unaided threshold > 30dB in the better ear) and incomplete data can cause delays or a request for repeat testing. Follow the flow: document whether hearing is normal by forced whisper >5 feet; if abnormal, complete the appropriate audiogram fields and add speech discrimination at 65dB when required, including aided and unaided results.
Missing required initials/signatures/stamps from the Medical Practitioner and applicant
This form is frequently rejected because the Medical Practitioner doesn’t initial/date each page where indicated, doesn’t sign the attestation in Section IX, omits license number/state/credential (MD/PA/NP), or the applicant forgets to sign Section X and date it. Since both parties attest under 18 USC § 1001, unsigned or partially signed forms are treated as incomplete and can’t be processed. Before submission, do a final checklist: MP initials/dates on each required page, MP signature and license details in Section IX (with office stamp/address), and applicant signature/date in Section X (and Section XI only if authorizing consents).

Frequently Asked Questions About CG-719K

 

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How does the AI fill out CG-719K?
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What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is CG-719K to fill out?
CG-719K has a Form Complexity Index of 89 out of 100, in the very complex tier: 460 fillable fields across 10 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is Form CG-719K used for?
CG-719K is the U.S. Coast Guard Application for Medical Certificate. It is used to determine whether you meet medical standards for issuance of a merchant mariner medical certificate (and related MMC medical qualification decisions).
Who must submit CG-719K?
Applicants seeking a Coast Guard Medical Certificate must complete the form and submit all 10 pages (including instructions) to the U.S. Coast Guard. Certain entry-level mariners requesting an MLC-compliant certificate may have reduced section requirements (see the entry-level/MLC question).
Do I have to submit all pages, even the instruction pages?
Yes. The instructions state you must submit all 10 pages, including the instruction pages, with your application.
Can I apply without a Mariner Reference Number or MMC?
No. The Coast Guard will not accept an application for a medical certificate without a reference number or a Merchant Mariner Credential (MMC). If you previously held a Coast Guard credential, use your reference number; otherwise follow NMC guidance for obtaining one.
What address should I use, and can I use a PO Box?
Your Home Address must be your principal place of residence and cannot be a PO Box. A PO Box is acceptable for the Delivery/Mailing Address if it is different from your home address.
What happens if I don’t check any boxes under “Endorsement Held or Sought” in Section I?
Your application will be rejected. The form states that if nothing is selected, the Coast Guard will not accept the application.
I’m under 18—what extra documentation is required?
If you are under 18, you must attach a notarized statement signed by a parent or guardian authorizing the Coast Guard to issue a Medical Certificate.
Who is allowed to conduct the medical exam for this form?
Exams, tests, and demonstrations must be performed, witnessed, or reviewed by a physician, physician assistant, or nurse practitioner licensed by a U.S. state/territory/possession. For U.S. Registered Pilots, the medical examination must be conducted by a licensed medical doctor (MD).
If I’m entry-level and only need an MLC-compliant medical certificate, do I still complete the whole form?
Not always. Entry-level mariners on non-STCW vessels who request an MLC-compliant medical certificate and want to be qualified for lookout duties do not have to complete Sections III (Medical Conditions), IV (Medications), and V (Physical Examination); the resulting medical certificate will be restricted to entry-level only.
What proof of identity do I need to show the Medical Practitioner?
You must present one current, valid government-issued photo ID to the Medical Practitioner. Examples include an unexpired passport, driver’s license, military ID, MMC, or TWIC.
How do I answer the Medical Conditions section (Section III(a))—what counts as “YES”?
Check “YES” if you have ever been diagnosed with, treated for, are currently under treatment/observation for, or currently have the condition (even if untreated). If a condition was previously reported, mark “PR,” and if you have a medical waiver, mark “MW” and provide a copy to the Medical Practitioner.
What does the Medical Practitioner need to write in Section III(b) if I mark a condition as YES or PR?
For each “YES,” the Medical Practitioner must document the condition, date of onset/diagnosis, treatment, current status, limitations, and any needed supporting information, and indicate if attachments are included. For “PR,” they generally only need to address interval history and current status.
What medications do I have to list in Section IV?
You must report all prescription and nonprescription medications, dietary supplements, and vitamins that you took or refilled within 30 days before you sign the form, and any that you used for 30 or more days within the last 90 days before signing. The Medical Practitioner must review and comment on duration of use and side effects.
Do the vision and hearing tests have to be performed by the Medical Practitioner personally?
No. Vision and hearing exams may be performed by qualified office staff or referred to other qualified practitioners (such as optometrists or audiologists), but the Medical Practitioner must review the results.
What are the optional consent/third-party authorization sections, and do I have to sign them?
Section XI is optional and lets you authorize (a) your Medical Practitioner to release information to the Coast Guard, (b) the Coast Guard to release information to a third party, and/or (c) a third party to act on your behalf. You are not required to sign these, but not authorizing release to the Coast Guard may delay a timely determination.
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