For Great Lakes: ATTN: Human Resources 4500 Division Avenue Cleveland, OH (216) Part I. (including area code)

Transcription

1 9. 8(a) For Great Lakes: ATTN: Human Resources 4500 Division Avenue Cleveland, OH (216) For Puerto Rico: ATTN: Human Resources Pier 15 Calle Miraflores Esq. Villa Verde San Juan, PR (787) Employment Application For a Conditional Job Offer Shipyard and Vessel Personnel (Directly affect safety or potentially dangerous) 1. Date of Application 2. Name INSTRUCTIONS: This application (Parts I, II, III and IV as applicable) for a Conditional Job Offer, must be completed in its entirety, and submitted with resume and required documentation (as indicated) to be considered for employment. Incomplete applications will not be considered. The Application consists of: Part I (to be completed by all applicants); Part II and Part III (to be completed by applicants for Vessel Positions Afloat and Ashore (e.g. tug crews, shipyard employees, and Part IV (OPTIONAL), (to be completed by veterans only) The Company may ask disability-related questions; require medical examinations and require submission of further documentation and information from an applicant after the applicant has been given a Conditional Job Offer. Upon receipt and review of requested submissions, documentation, and information, to the satisfaction of the Company, the Company may make a Conditional Job Offer to the applicant, and require an interview, but the Company is under no obligation to do so. Applications are considered active for 45 days, at which point applicants not hired must reapply. Completeness and neatness of this application will be used in considering suitability of applicant for the position applied for. If information is not applicable, then write "N/A". DO NOT leave any blanks. DO NOT write in the shaded areas. Equal Opportunity/Affirmative Action Employer We ensure that all individuals have an equal opportunity for employment, without regard to race, color, religion, sex, national origin, disability or status as a veteran. question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Our company Affirmative Action Program refers to our aggressive recruitment programs, mentoring, training, and family programs that work to recruit and retain qualified individuals. Equal access to employment services and programs are available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify the Company personnel representative at the address shown above. Part I (Month) (Date) (Year) (First) (M.I.) (Maiden-Optional) (Last) 3. Social Security Number 4. Home Telephone Number (including area code) 5. Address 6. Mobile or Other Telephone Number where you can be reached (including area code) 7. Driver's License. 10. Emergency Contact and Relationship to you 7(a) State of Issue 7(b) Expiration Date (Month, Day, Year) 8. Are you a U.S. Citizen If, Do you have a Current Work Visa 8(b) If, Country of Issue (Contact) (Relationship) 11. Emergency Contact s Telephone Number (including area code) 12. Second Emergency Contact s Telephone Number (including area code) 8(c) Expiration Date (Month, Day, Year) 9. Do You Have a Passport? 13. Emergency Contact s Address 9(a) If so, Expiration Date (Month, Day, Year)

2 14. Birth Place: (City) (State) (Country) 15. Present Mailing Address Street Apartment Number City State ZIP Code 16. Permanent Mailing Address (Indicate "same" if same as block 15.) Street Apartment Number City State ZIP Code 17. Date Available to Start Work Check here, if immediately available, or enter date: Month Day Year 18. Which Company are you applying to? (Check all that apply) The Great Lakes Towing Company Puerto Rico Towing & Barge Co. SM Soo Linehandling Services, Inc. Other (Specify) 19. Location Preference (Check all that apply) Cleveland, OH (Hqtrs.) Great Lakes Ports Sault Ste. Marie, MI If specific port(s) are desired, specify: Other (Specify) 20. Which position are you applying for? (Check all that apply) (a) Vessel Afloat (b) Vessel Ashore (c) Office Position Captain Engineer Deckhand/Acting Engineer Deckhand Captain - Alternate Engineer - Alternate Other (Specify) Port Captain Port Engineer Shipyard Employee Yardman Other (Specify) (d) Linehandling Linehandler Accounting General Admin Engineering Operations Sales & Marketing Secretarial Other (Specify) 21. Education and Training 21(a) High School (Write the name and location of the last high school you attended or where you obtained your GED high school equivalency) Name of High School City State Years Completed (Check) (b) Did you receive a diploma? If NO, Did you receive a GED equivalency? 21(c) Have you ever attended college or graduate school? YES if yes continue to block 21(d) If NO, go to block 21(g) 21(d) College/University Name of College/University School City State ZIP Code Month and Year Attended Number of Credit Hours Completed Type of Degree Month and Year of Degree Month Year Semester Quarter (e.g. BA, MA) Month Year Page 2

3 21. Education and Training (continued) 21(e) Chief Undergraduate Subjects Number of Credit Hours Chief Graduate Subjects Number of Credit Hours (Show Major on the first line) Semester Quarter (Show Major on the first line) Semester Quarter 21(f) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School City State ZIP Code Month and Year Attended Month Year Class Room Hours Subject(s) Training Completed (Check Box) 21(g) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School City State ZIP Code Month and Year Attended Month Year Class Room Hours Subject(s) Training Completed (Check Box) 21(h) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School City State ZIP Code Month and Year Attended Month Year Class Room Hours Subject(s) Training Completed (Check Box) 21(i) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School City State ZIP Code Month and Year Attended Month Year Class Room Hours Subject(s) Training Completed (Check Box) 21(j) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School City State ZIP Code Month and Year Attended Month Year Class Room Hours Subject(s) Training Completed (Check Box) Page 3

4 22. Employment History Please start with your most recent job, and list your last four (4) employers or your employers during the past five (5) years. All past five (5) years of employment must be included. Attach additional sheets as necessary. Include military service assignments and volunteer activities. This information must be detailed below. If a resume is attached or has been previously submitted, ONLY include information that IS NOT on the resume. (Make sure you list Employer name with this information) 22(a) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR (b) Name of Present or Last Employer 22(c) Address Street Suite Number City State ZIP Code 22(d) Present or Last Job Title 22(e) Dates of Present or Last Employment Month Year To Month Year 22(f) Name of Present or Last Supervisor 22(g) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers 22(h) Salary History (Present or Last salary held. Must be indicated in order for consideration) Wage (Per Hour, Day, Month, or Year as checked) Per (Check One): $ Hour Day Month Year 22(i) Duties Performed 22(j) Reason for Leaving Page 4

5 22. Employment History (continued) 22(k) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR (l) Name of prior Employer 22(m) Address Street Suite Number City State ZIP Code 22(n) Prior Job Title 22(o) Dates of Prior Employment Month Year To Month Year 22(p) Name of Prior Supervisor 22(q) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers 22(r) Salary History (Last salary held) Wage (Per Hour, Day, Month, or Year as checked) Per (Check One): $ Hour Day Month Year 22(s) Duties Performed 22(t) Reason for Leaving Page 5

6 22. Employment History (continued) 22(u) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR (v) Name of prior Employer 22(w) Address Street Suite Number City State ZIP Code 22(x) Prior Job Title 22(y) Dates of Prior Employment Month Year To Month Year 22(z) Name of Prior Supervisor 23(aa) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers 22(bb) Salary History (Last salary held) Wage (Per Hour, Day, Month, or Year as checked) Per (Check One): $ Hour Day Month Year 22(cc) Duties Performed 22(dd) Reason for Leaving Page 6

7 22. Employment History (continued) 22(ee) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR (ff) Name of prior Employer 22(gg) Address Street Suite Number City State ZIP Code 22(hh) Prior Job Title 22(ii) Dates of Prior Employment Month Year To Month Year 22(jj) Name of Prior Supervisor 22(kk) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers 22(ll) Salary History (Last salary held) Wage (Per Hour, Day, Month, or Year as checked) Per (Check One): $ Hour Day Month Year 22(mm) Duties Performed 22(nn) Reason for Leaving Page 7

8 23. Professional References (List three [3] persons not listed in blocks 22(f), 22(p), 22(z), or 22(jj) who are not related to you, and who are familiar with you) 23(a) Name 23(b) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers May we contact? 23(c) Address Street Suite Number City State ZIP Code 23(d) Nature of association with you 23(e) Name 23(f) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers May we contact? 23(g) Address Street Suite Number City State ZIP Code 23(h) Nature of association with you 23(i) Name 23(j) Telephone Number (First) (Last) Area Code Prefix Last 4 Numbers May we contact? 23(k) Address Street Suite Number City State ZIP Code 23(l) Nature of association with you Page 8

9 24. Professional, Educational or Civic Organizations (List memberships as indicated. You may exclude those which may disclose your race, color, religion or national origin) 24(a) Name of Organization City State May we contact? 24(b) Type of Organization 24(c) Nature of Membership 24(d) Dates of Membership: Month & Year Month & Year TO 24(e) Name of Organization City State May we contact? 24(f) Type of Organization 24(g) Nature of Membership 24(h) Dates of Membership: Month & Year Month & Year TO 24(i) Name of Organization City State May we contact? 24(j) Type of Organization 24(k) Nature of Membership 24(l) Dates of Membership: Month & Year Month & Year TO 25. Active Military Service 25(a) Have you served in the United States Military Service? (If your only active duty was training in the Reserves or National Guard, answer "NO". If "YES" See attached Supplemental Part IV (Optional) - Special tice to Covered Veterans 25(b) Did you retire? 25(c) Were you discharged from the military service under honorable conditions? (if your discharge was changed to "honorable" or "general" by a Discharge Review Board, answer "YES". If you receive a clemency discharge, answer "NO".) If "NO", provide the date and type of discharge you received below: Month Day Year Type of Discharge 25(d) If last employment was military service, attach copies of DOD Form DD-214 and, at the applicants option, attach your last three (3) performance evaluations prior to discharge. Page 9

10 26. Referral Information 26(a) How did you hear about the Company? (Check all that apply) Newspaper ad Friend Employee Union Website Other (Specify) 26(b) Were you referred by someone? (Check Box) If yes, by whom? Name (First) (Last) 26(c) May we contact them for reference? 26(d) Have you ever applied to, or worked for a Company in the Great Lakes Group of Companies before? If yes, name of Company and when? Name of Company Date Month Day Year 27. Additional Questions NOTE: It is important that you give complete and truthful answers to questions below. If you answer "YES" to any of them, provide your explanation(s) in block 27(g). Include convictions resulting from a plea of nolo contenders (no contest). Omit: (1) traffic fines of $ or less; (2) any violation of law committed before your 16 th birthday; (3) any violation of law committed before your 18 th birthday, if finally decided in juvenile court or under a Youth Offender law; (4) any violation of law aside under the Federal Youth Corrections Act or similar state law; (5) any conviction whose record was expunged under Federal or state law. We will consider the date, facts, and circumstances of each event you list. In most cases you can still be considered for employment. However, if you fail to tell the truth or fail to list all relevant events or circumstances, this may be grounds for not hiring you, or for firing you after you begin work 27(a) During the last five (5) years, were you fired from any job for any reason, did you quit after being told you would be fired, or did you leave by mutual agreement because of specific problems? 27(b) Have you ever been convicted of, or forfeited collateral for any felony violation? (Generally, a felony is defined as any violation of law punishable by imprisonment of longer than one (1) year, except for violations called misdemeanors under State law which are punishable by imprisonment of two (2) years or less). 27(c) Have you ever been convicted, or forfeited collateral for any firearms or explosives violation? 27(d) Are you now under charges for any violation of law? 27(e) During the last five (5) years have you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not include violations reported in 27(b), 27(c), or 27(d), above. 27(f) Have you ever been convicted by a military court martial? If no military service, answer "NO". 27(g) If "YES" in block 27(a): Explain for each job the problem(s) and your reason(s) for leaving. Give the employer's name and address. If "YES" in blocks 27(b) through 27(f): Explain each violation. Give place of occurrence and name/address of police or court involved. Item. Month & Year Explanation Mailing Address (Name of employer, Police, Court or Agency) Item. Month & Year Explanation Mailing Address (Name of employer, Police, Court or Agency) Page 10

11 Item. Month & Year Explanation Mailing Address (Name of employer, Police, Court or Agency) Item. Month & Year Explanation Mailing Address (Name of employer, Police, Court or Agency) Item. Month & Year Explanation Mailing Address (Name of employer, Police, Court or Agency) Item. Month & Year Explanation Mailing Address (Name of employer, Police, Court or Agency) 28. Representations 28(a) Attendance: The Company is a service provider and employee attendance is critical to meet customer service demands. (i) Are you able to meet the Company's attendance requirements? (ii) How many days, other than vacation days, were you absent from your last job? Less than More than 10 (iii) How many Mondays or Fridays were you absent last year on leave other than approved vacation leave? Number of Mondays Number of Fridays (iv) Do you have any objection to working overtime if necessary? 28(b) Illegal Drug Use / Medical History: (i) Have you ever used illegal drugs? (ii) Have you used illegal drugs within the last six (6) months? If yes, when was the last time you used illegal drugs? (ii) Have you ever been convicted for driving under the influence of illegal drugs or alcohol? 28(c) General Employment Information (i) Can you travel if required by this position? (ii) Can you submit proof of legal employment authorization and identity as required by governmental authorities? (iii) Are you under eighteen (18) years of age? (iv) Can you perform any or all job functions for the position applied for, with or without reasonable accommodation? Page 11

12 29. Certifications 29(a) I understand that the Company's Policy on Alcohol, Drugs and Controlled Substances requires Chemical Testing for employees as listed below. I am willing to participate in the required Pre- Employment Chemical Test and, if hired, to comply with the aforementioned Company policy. (a) Initial I. Vessel Employees Afloat: Pre-Employment, Periodic, Random, Reasonable Cause, Post-Accident Testing. a. Any person, tugman, or crew member engaged or employed on board a Company tug, barge, vessel, or equipment acting under the authority of a license, certificate of registry, or merchant mariner's document, whether or not a member of the Company tug's crew; b. Any person employed shore side as an employee or supervisor, who, by virtue of his or her shore side position, may be engaged or employed on board a Company tug acting under authority of a license, certificate of registry, or merchant mariner's document, whether or not the employee is a member of the Company tug's crew. II. Vessel Employees Ashore, Shipyard Employees and Linehandlers: Pre-Employment, Periodic, Random, Reasonable Cause, Post-Accident Testing. a. Any person engaged in duties which directly affect the safety of a Company tug's navigation or operations, or whose duties involve potentially dangerous and hazardous work that may endanger the safety of either themselves or other employees. b. All Company shipyard, or other Company maintenance facility employees (excluding administrative and clerical personnel); c. All other employees who perform repair and maintenance, construction, and reconstruction duties on board vessels and the dry dock; d. All Soo Linehandling Services, Inc. employees (excluding administrative and clerical personnel); and Employees, in various ports III. Administrative (including Management and Clerical) Personnel: Reasonable Cause Testing. a. All shore side employees performing administrative, management, and clerical duties who are not engaged or employed on board a Company tug, barge, or vessel. b. Any person engaged in duties which DO NOT directly affect the safety of a Company tug's navigation or operations, or whose duties DO NOT involve potentially dangerous work that may endanger the safety of either themselves or other employees. 29(b) I certify that the information provided in this employment application for a Conditional Job Offer (and accompanying resume, or documentation, if any) is true and complete, and I understand that any false or misleading information, misrepresentation or material omission may disqualify me from further consideration for employment or immediate termination of employment, if I am employed, whenever it may be discovered. I agree to immediately notify the Company if I should be convicted of a felony, of any crime involving dishonesty, breach of trust, controlled substances, sexual misconduct, abuse, or violence, while my job application is pending, or during my period of employment if hired. (b) Initial Page 12

13 29. Certifications 29(c) I understand that I am authorizing the release of pre-employment information gained through my employment references. This is to allow the Company to verify and, in the Company's discretion, to perform other background investigations to determine my qualification for employment. Further, I understand that the Company, through a separate Company may investigate my academic credentials, prior employment, personal/professional references, credit record, motor vehicle record, and/or criminal record. I understand that a report may include information obtained through personal interview regarding your character, general reputation, personal characteristics, and/or mode of living. I understand that I may make a written request to obtain a description of the nature and scope of any report, which is prepared regarding me. 29(d) I understand that this Application is for a Conditional Job Offer and does not constitute an offer or create a contract of employment. I understand that if an offer of employment is made, and if hired, I am obliged to comply with the Company' current and subsequently adopted policies, including the Company's Employment Manual, the Company's Policy on Alcohol, Drugs and Controlled Substances, and the Company's Responsible Carrier Program Manual. I am also aware that the aforementioned Company Policies on Alcohol, Drugs, and Controlled Substances, among other things, prohibits the use and possession of intoxicants (dangerous drugs and alcohol) on Company property and vessels, and that violation of the Policies will result in disciplinary action, including suspension, and may result in termination of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time, for any reason, with or without notice. Accordingly, either the Company or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal law or state law. I understand that no person is authorized to change any of the items mentioned in this employment application for a Conditional Job Offer. 29(e) I understand that if employed in a temporary position, I will not be entitled to health and other benefits afforded employees in permanent positions. 29(f) I understand that it is the Company's policy not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the Americans with Disabilities Act. 29(g) I understand that once I am offered a conditional job offer and I accept, I will be required to provide satisfactory proof of identity and legal work authorization before my initial start date. Failure to submit such proof and/or the Company not being able to confirm legal work authorization through the E- Verify process, my conditional job offer with the company will be provoked. 29(h) I understand that once I am offered a conditional job offer and I accept, a criminal background check will be performed. If I have not been totally honest with the Company on my background, my conditional job offer with the company will be provoked. (c) Initial (d) Initial (e) Initial (f) Initial (g) Initial (h) Initial I represent and warrant that I have read and fully understand the foregoing and that I seek employment under these conditions. Applicant s Signature ADMINISTRATIVE (Including Management and Clerical) STOP HERE UNLESS A VETERAN: If a Veteran - Complete Part IV (Optional) Page 13

14 Part II Supplemental Employment Application To be completed by Applicants seeking Vessel Positions Afloat and Ashore (including Shipyard) Only (If you are applying for an Office or Linehandling Position listed, DO NOT complete this Part II, unless also applying for a Vessel Position Afloat and/or Ashore) 30. U.S. Coast Guard Licenses and Document Information 30(a) Do you possess a U.S. Coast Guard Merchant Mariner Document? (If, Complete blocks 30(b), 30(c), and 30(d) below) 30(f) Do you possess a U.S. Coast Guard License as a Captain, Mate, or Engineer? (If, Complete blocks 30(f), 30(g), and 30(h) below) 30(b) Ratings held and expiration date: (If temporary, so state) 30(f) Licenses held and expiration date: (Ratings) Month Day Year (Licenses) Month Day Year 30(c) Do you have a life boat endorsement? 30(d) List all limitations and endorsements listed on the back of your U.S. Coast Guard Merchant Mariners Document below: (Limitations and endorsements) 30(g) List all limitations and endorsements listed on your U.S. Coast Guard licenses below: (Limitations and endorsements) 31. Tug Experience 30(h) For licensed Captain/Deck officers: Are you a qualified RADAR observer? 31(a) Do you have experience with the following type tugs? a. Conventional Single Screw Tugs b. Conventional Twin Screw Tugs c. Tractor Tugs d. Reverse Tractor Tugs e. Z-Drives f. Cycloidal Propulsion g. Other (Specify) 31(b) Do you have experience with the following type of tug work? a. Harbor Docking/Ship assistance b. Escorting c. Tug Barge Units d. Other (Specify) Page 14

15 32. For applicants seeking Vessel positions Ashore (e.g. Port Captain, Port Engineer, Shipyard Employee, Yardman), indicate the level of experience you have had with the tools listed in block 34(a) and in performing the duties listed in block 34(b) using the scale below: SCALE 0 - Indicates that you have not had any training or work experience 2 - Indicates that you have used/performed alone with little supervision 1 - Indicates that you have trained, but never had work experience 3 - Indicates that you have used/performed and trained or supervised others 32(a) Use the Scale above to indicate your level of experience with the following tools or equipment: Pliers Hammer Screwdriver File Chisel Wrench Power Saw Portable Drill Power Shaper Mortiser Router Metal Shears Lathe Jointer Scrapper Power Sprayer Fork Lift Hand Truck Dolly Power Winch Grease Gun Impact Wrench Soldering Iron Wire Strippers Basic Voltmeter/Ohmmeter Hydraulic Bender Fire Extinguisher Other (Please Specify) 32(b) Use the Scale above to indicate your level of experience in performing the following duties: Installed electrical cable Spliced cable Repaired telephone equipment Repaired electrical equipment & systems on ships Maintained electrical equipment & systems on ships Repaired electric motors Worked in a steam plant Worked in a diesel plant Worked as a machinist or welder Welded to fine tolerances Welded using processes such as brazing, beading, pressure welding, tack welding Worked as a pipefitter Repaired air conditioning equipment Repaired refrigeration equipment Painted metal surfaces (aircraft, ships, automobiles, etc.) Prepared metal surfaces for painting Painted surfaces other than metal (plastic, wood, etc.) Mixed paints, varnishes, stains Climbed ladders Handled heavy loads Worked in high places Worked with formal supply systems Performed inventory duties Maintained storerooms/stockrooms Maintained stock records Maintained budget records Planned for & ordered stock/parts Planned storage schemes Arranged items stored to allow for maximum use of space & proper issue Stored supplies Worked as an administrative assistant Worked in a payroll office Used instruction manuals Operated computer terminals Operated office machines Other (Please Specify) Page 15

16 PART II (CONTINUED) 33. For applicants seeking Vessel positions Afloat and Ashore (e.g. Captain, Engineer, Deckhand, Port Captain, Port Engineer, Shipyard Employee, Yardman), indicate the level of experience you have had with the tools listed in block 33(a) and in performing the duties listed in block 33(b) using the scale page 15: 33(a) Use the Scale on page 15 to indicate your level of experience with the following tools or equipment: Diesel Engines (Main Propulsion) Diesel Engines (Generators and/or small gasoline engines [small boat]) Chipping Hammer (pneumatic) Deck Winches Bow Thruster Pumps Booms Boilers (Main) After Steering Engine Davits Ventilation Systems (HVAC) Fathometer Steering System (Bridge) Main Electrical Switchboard Anchor Windlass Capstans Automated Bridge Control AC Generators DC Generators Boiler water supply equipment Compressors Collision Avoidance Radar Gyro Compass (Master) Life boats Fire Detector System CO 2 Extinguishing System Inert Gas System Global Positioning System (GPS) Others (Please Specify) 33(b) Use the Scale on page 15 to indicate your level of experience in performing the following duties: Operated hydraulic equipment Repaired valves Tied knots Used life-saving equipment Chipped paint Spliced wire rope Spliced other rope (fiber) Operated davits Worked on slippery surfaces Handled lines Maintained engine machinery Took tank soundings Operated valves Lubricated engine equipment Used various lubricants Disassembled engine room equipment Assembled engine room equipment Read electrical meters Read mechanical gauges Cleaned burners Fired oil burners Assembled & disassembled burners Changed & cleaned strainers Operated & maintained burners Transferred fuel between tanks Pumped bilges Steered by Gyro Compass Steered by magnetic compass] Kept vessel on course Used navigational aids Used navigational rules & regulations Operated gas engines Operated diesel engines Packed shafts and bearings Repaired small boat hulls Performed preventive maintenance on engines Gas free engineer certified Installed hardware & fittings on launches Towed floating equipment with a launch Lubricated deck machinery Operated booms Rigged booms Stood anchor watch Stood gangway watch Stood bridge watch (underway) Stood engineroom watch (in port) Launched life boats Commanded life boars (oars) Tested boiler water Operated lube oil purifier Operated evaporators Operated main throttle Operated remote shut down devices for machinery spaces Operated machine lathe Fabricated parts Service storage batteries Kept deck log Kept engineering log Knowledge of ship trim and stability Cargo storage Slushed standing rigging Lubricated running rigging Serviced damage control lockers and equipment Used all types of firefighting equipment Taken on fuel, lube oil, and water Knowledge of computers - Vessel application Operated computerized cargo systems Other (Please Specify) Page 16

17 Part II (Last Page) Indicate training completed in the following areas by checking the appropriate box. In block 34(a) list other maritime training received such as courses in GYRO-COMPASS and RADAR. In block 34(b), list licenses and certificates you hold other than those issued by the U.S. Coast Guard. Certified Swimmer CPR/First Aid RADAR Operation Diver (Shallow Water) Diver (Deep Water Lifeboatman Radio Operator (FCC) Radio Operator (CB) GYRO-COMPASS GPS HASWOPR (Date ) Other (Specify) 34(a) List of other maritime training received: 34(b) List of licenses and certificates you hold other than those issued by the U.S. Coast Guard: 35. On what type of vessels have you served? Tug/Vessel Name Tug/Vessel Type Company Position(s) Held 36. In what geographical areas have you worked? Please list the areas in which you have worked on board the above vessels, including any particularly noteworthy areas (i.e. river systems, difficult docking areas, etc.) Tug/Vessel Name Tug/Vessel Type Company Geographical Area 37. Have you ever been involved in any USCG-reportable accident?, If yes, explain in blocks 37(a) and 37(b), 37(a) Date of Accident Type of Accident Accident Details Month Day Year (Accident details continued) 37(b) Date of Accident Type of Accident Accident Details Month Day Year (Accident details continued) 38. Photocopies (front &back) of documents required to be submitted with application for a Conditional Job Offer, Vessel Afloat & Ashore. 38(a) U.S. Coast Guard Merchant Mariners Document with endorsements as OS, AB, TANKERMAN, etc. 38(b) U.S. Coast Guard Captain, Mate and/or Engineer's License (if held) 38(c) FCC Marine Radio Operator Permit (f held) 38(d) RADAR Observer Certificate (if held and not included as an endorsement on U.S. Coast Guard License) Applicant's Signature for Vessel Afloat, Vessel Ashore, and Shipyard positions Date of Signature: Month, Date & Year Page 17

18 Part III CONFIDENTIAL DRUG & ALCOHOL TESTING CONSENT TO RELEASE INFORMATION DOT REGULATION 49 CFR Part Name (First) (Middle) (Maiden-Optional) (Last) 40. Address Street Apartment Number City State ZIP Code 41. Social Security Number 42. Home Telephone Number (Including area code) I hereby authorize my previous employer(s) that are covered by Department of Transportation Drug Testing Regulations (listed below list all employers for the previous 24 months) to release the following information with regard to my chemical testing records to any one of, or to each of, of Companies: 44. Date of Signature 43. Applicant's Signature (Month, Day & Year) 45. Name of prior DOT Employer 45(a) Name of Contact Person (First and Last name) 45(b) Telephone Number (including area code) 45(c) Dates of Prior Employment: Month & Year Month & Year TO 45(d) Name of prior DOT Employer 45(e) Name of Contact Person (First & Last Name) 45(f) Telephone Number (including area code) 45(g) Dates of Prior Employment: Month & Year Month & Year TO Page 18

19 Part III (Last Page) 45(h) Name of prior DOT Employer 45(i) Name of Contact Person (First & Last) 45(j) Telephone Number (Including area code) 45(k) Dates of Prior Employment: (Month & Year) (Month & Year) TO 45(l) Name of prior DOT Employer 45(m) Name of Contact Person (First & Last) 45(n) Telephone Number (Including area code) 45(o) Dates of Prior Employment: (Month & Year) (Month & Year) TO 45(p) Name of prior DOT Employer 45(q) Name of Contact Person (First & Last) 45(r) Telephone Number (Including area code) 45(s) Dates of Prior Employment: (Month & Year) (Month & Year) TO 45(t) Name of prior DOT Employer 45(u) Name of Contact Person (First & Last) 45(v) Telephone Number (Including area code) 45(w) Dates of Prior Employment: (Month & Year) (Month & Year) TO 45(x) Name of prior DOT Employer 45(y) Name of Contact Person (First & Last) 45(z) Telephone Number (Including area code) 45(aa) Dates of Prior Employment: (Month & Year) (Month & Year) TO Page 19

20 Part IV Supplemental Employment Application - (OPTIONAL) SPECIAL NOTICE TO COVERED VETERANS Disabled, Other Protected, Armed Forces Special Medal, and Recently Separated Veterans Government contractors are subject to 38 U.S.C of the Covered Veterans Veterans Employment Emphasis under Federal Contracts. Revised law went into effect as of January 7, This revised law requires that government contractors take affirmative action to employ and advance qualified Covered Veterans in employment. The term Covered Veteran means any of the following veterans: 1. Disabled Veteran: Any veteran that served on active duty in the U.S. military ground, naval, or air services and is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs, or was discharged or released from active duty because of a service-connected disability. 2. Other Protected Veteran: Any veteran who served on active duty in the U.S. military ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge was authorized. 3. Armed Forces Special Medal Veteran: Any veteran who, while serving on active duty in the U.S. military ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order (61 Fed. Reg. 1209). 4. Recently Separated Veteran: Any veteran who served on active duty in the U.S. military, ground, naval or air service during the three-year period beginning on the date of such veteran s discharge or release from active duty. USERRA (The Uniformed Services Employment and Reemployment Rights Act) requires employers to go further than the ADA by making reasonable efforts to assist a veteran who is returning to employment in becoming qualified for a job. The employer must help the veteran become qualified to perform the duties of the position whether or not the veteran has a service-connected disability requiring reasonable accommodation. This could include providing training or retraining for the position. Additionally, reasonable accommodations may be available under USERRA for individuals whose service-connected disabilities may not necessarily meet the ADA s definition of disability. USERRA also applies to all employers, regardless of size. Information on the reemployment rights of uniformed service personnel can be found on DOL s website at If you are a disabled veteran, or have a physical or mental handicap you may volunteer this information which will be treated as confidential. Additionally, not providing this information will not jeopardize or adversely affect your consideration for employment. If you wish to be identified, please check the appropriate box(es) and sign below. Submission is voluntary Disabled Veterans Other Protected Veterans Armed Forces Special Medal Veterans Recently Separated Veterans THE AMERICANS WITH DISABILITIES ACT (ADA) AMENDMENTS ACT OF 2008 Title I of the Americans with Disabilities Act (ADA) prohibits private and state and local government employers with 15 or more employees from discriminating against individuals on the basis of disability. Title I of the ADA also generally requires covered employers to make reasonable accommodations changes in the workplace or in the way things are usually done that provide individuals with disabilities equal employment opportunities. The ADA makes it unlawful to discriminate in employment against a qualified individual with a disability, therefore, providing this information will not jeopardize or adversely affect your consideration for employment. Additionally, not providing this information will not jeopardize or adversely affect your consideration for employment. If you wish to be identified as an individual with a disability, please check:, I am an individual with a disability. Signature Date of Signature (Month, Day & Year) Page 20

21 Page 21