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CG-719B (04/17)Page 1 of 5 DEPARTMENT OF HOMELAND SECURITY OMB No. 1625-0040 Coast Guard Exp. Date: 03/31/2021 APPLICATION FOR MERCHANT MARINER CREDENTIAL (FORM CG-719B)------ Instructions ------1. Applicants seeking a Merchant Mariner Credential (MMC), whether original, renewal, duplicate, raise of grade, or a new endorsement on a previously issued MMC and applicants requesting a Medical certificate . 2. Application Assistance: Please call the National Maritime Center (NMC) at 1-888-IASKNMC (1-888-427-5662), or visit their website for more information. I: Applicant Name - Enter complete legal name. Include any aliases you have used and your maiden or prior name(s).

(Including Certificate of Registry) I.7a . Next of Kin/Emergency Contact - Name & Mailing Address, City, State, Zip Code. I.7b . Relationship - Provide relationship status to next of kin listed on application. (i.e. Mother, Father, Spouse) I.7c. Primary Phone Number - Phone number to contact the person listed in the event of an emergency. I.7d

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