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APPLICATION FOR US ARMY MARINE CERTIFICATION For use of this form see AR 56-9 the proponent agency is ODCSLOG PRIVACY ACT STATEMENT AUTHORITY Title 10 USC Section 3013 and E.O. 9397 SSN PURPOSE Provide information necessary for issuance of Marine Certification Examination and provide identification of examinees ROUTINE USES In addition to those disclosures generally permitted under 5 U*S*C. 522a b of the Privacy Act these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U*S*C. 522a b 3 as follows The U*S* Coast Guard Department of Transportation may be furnished information concerning certification and licensing of individuals. DISCLOSURE Disclosure of information is mandatory per AR 56-9. READ BEFORE SIGNING Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by trick scheme or device a material fact or makes or uses any false writing on a document knowing the same to contain any false fictitious or fraudulent statement or entry shall be fined not more than 10 000 or imprisonment of not more than 5 years or both. 18 USC 1001 1. TYPE OF CERTIFICATION Check one ORIGINAL RENEWAL UPGRADE 2. NAME Last First MI ENDORSEMENT 3. GRADE 5. SOCIAL SECURITY NUMBER 4. DOR 6. PRIMARY MOS 7. UNIT OF ASSIGNMENT 8. APPLICANTS SIGNATURE 9. DATE YYYYMMDD PHYSICAL STATEMENT In accordance with AR 56-9 Watercraft Physical Standards 1. Profile serial MUST be 2 or better for P U L H E and be 1 for S* 2. MUST pass color perception using the Pseudoisochromatic Plate PIP test and have visual acuity required by Chapter 5-2. 10. PROFILE 11. DATE OF LAST PHYSICAL YYYYMMDD P U L H E S 12. MEDICAL CORPS/MEDICAL SERVICE CORPS SIGNATURE Required 15. TITLE 16. VERIFICATION DATE YYYYMMDD 17. COLOR PERCEPTION 17a* TEST TYPE 14. MOS/BRANCH 17b. SCORE / 18. VISUAL ACUITY 18a* UNCORRECTED R PASS 18b. CORRECTED 19. OPTOMETRIST SIGNATURE Required 20. GRADE 22. TITLE FAIL APPLICATION IS VALID FOR ONE YEAR FROM ABOVE DATE 24. COMMANDER S AUTHENTICATION 25. COMMANDER S SIGNATURE DA FORM 7434 MAY 2001 APPROVED USAPA V1. 9397 SSN PURPOSE Provide information necessary for issuance of Marine Certification Examination and provide identification of examinees ROUTINE USES In addition to those disclosures generally permitted under 5 U*S*C. 522a b of the Privacy Act these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U*S*C. 522a b of the Privacy Act these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U*S*C. 522a b 3 as follows The U*S* Coast Guard Department of Transportation may be furnished information concerning certification and licensing of individuals. 522a b 3 as follows The U*S* Coast Guard Department of Transportation may be furnished information concerning certification and licensing of individuals. DISCLOSURE Disclosure of information is mandatory per AR 56-9. READ BEFORE SIGNING Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by trick scheme or device a material fact or makes or uses any false writing on a document knowing the same to contain any false fictitious or fraudulent statement or entry shall be fined not more than 10 000 or imprisonment of not more than 5 years or both.