SouthEast Alaska Pilots Association 1621 Tongass Avenue, Suite 300 Ketchikan, Alaska fax

Transcription

1 SouthEast Alaska Pilots Association 1621 Tongass Avenue, Suite 300 Ketchikan, Alaska fax APPLICATION FOR SOUTHEAST ALASKA PILOT S ASSOCIATION - TRAINEE SELECTION PERSONAL INFORMATION Name: Date: (First) (Middle) (Last) Social Security Number: / / DOB: U.S. Citizen: Yes No Alaska State Resident: Yes No Present Address and Contact Information: Primary Contact Telephone Nr (mandatory) Address (mandatory): Alternate Contact Information: EDUCATION High School Graduate: Yes No (Must be a High School Graduate) College: Last Year Completed: College Degree Major: PROFESSIONAL SCHOOLS AND TRAINING (Use additional sheets if necessary) / / (School) (Course / Training) (Date) / / (School) (Course / Training) (Date) / / (School) (Course / Training) (Date) SEAPA Application Form

2 SOUTHEAST ALASKA PILOT S ASSOCIATION TRAINEE APPLICATION PAGE 2 OF 5 UNITED STATES COAST GUARD LICENSE INFORMATION USCG License Information: (Provide copy of front and back of license) USCG License Number: Issue Number: Pilotage Endorsements: Have you ever had an action taken against your U.S. Coast Guard License? Yes / No If yes, please explain: EMPLOYMENT HISTORY (Attach additional sheets as necessary) SEAPA Application Form

3 SOUTHEAST ALASKA PILOT S ASSOCIATION TRAINEE APPLICATION PAGE 3 OF 5 WORK EXPERIENCE (Attach additional sheets as necessary) PILOTING EXPERIENCE: On vessels NLT (not less than) 1600 GT Number of Years AND Movements: / DEEP DRAFT EXPERIENCE: Qualifying service only on self-propelled vessels NLT 1600 GT or 3000 ITC or U.S. commissioned vessels NLT 200 feet length over all. Master / Command Deep Draft Experience Chief Mate / Staff Captain / Executive Officer Deep Draft Experience Master / Command Deep Draft Experience on self-propelled vessels NLT 10,000 GT TUG AND TOWING VESSEL EXPERIENCE: Master Experience on tugs conducting ship assist work Master Experience on tugs with tows combined tonnage NLT 1600 GT Chief Mate Experience on tugs with tows combined tonnage NLT 1600 GT ALASKA EXPERIENCE: Master Experience in Alaska? RECENCY: Is any of the above experience within the previous seven (07) years? If yes to any of the above, provide documentation to support experience that clearly documents the amount of time claimed. SEAPA Application Form

4 SOUTHEAST ALASKA PILOT S ASSOCIATION TRAINEE APPLICATION PAGE 4 OF 5 OTHER INFORMATION If a yes answer is given to a question, provide a complete explanation on a separate page. Have you ever been convicted of a felony? Have you ever been convicted of any repeat misdemeanor offenses involving the illegal use of alcohol? Have you ever had a conviction involving the possession, use, or sale of drugs? Have you ever had a marine or motor vehicle driver s license revoked or suspended or limited in any jurisdiction? CHECK LIST Attach copy (front and back) of valid U.S. Coast Guard license Attach three (03) letters of reference from previous employers Attach three (03) letters of reference from previous vessel Masters you Have worked with Attach copies of documented sea-service time and experience Attach copy of current drug test (within 6 months) or letter of enrollment In random drug testing program Attach documentation of explanation to any yes answers above Attach a check for $50.00 (nonredundable) made payable to Southeast Alaska Pilots Association SEAPA Application Form

5 SOUTHEAST ALASKA PILOT S ASSOCIATION TRAINEE APPLICATION PAGE 5 OF 5 APPLICANT S AGREEMENT AND CERTIFICATION I certify that the information given by me on this application is true in all respects, and I agree that if the information given is found to be false in any way, it shall be considered sufficient cause for disqualification as an applicant. I authorize the use of any information in this application to verify my statements, and I authorize abovelisted employers, references and any other persons to answer all questions asked concerning my ability, character, reputation and previous employment record. I release and hold harmless all such persons from any liability or damages on account of having furnished such information. Further I authorize the release of the information provided on this application to the Southeast Alaska Pilots Association to evaluate my qualifications for selection for a training position. I understand that a failure to submit a complete application may be grounds for disqualification from the application process. I hereby request that personal information contained in this application be kept confidential and exempted from public records disclosure. I certify that I have read and understand the instructions to applicants on the SEAPA website. I acknowledge the availability for download and review from the SEAPA website the USCG Southeast Alaska Federal Pilotage package; the State of Alaska Marine Pilot Statutes and Regulations and the Southeast Alaska Pilots Association Training Program Volume I: Trainee Application, Evaluation, and Selection. I understand that nothing contained in this application or in the authorization to complete the evaluation and selection process constitutes a promise or guarantee of acceptance as a Southeast Alaska Pilots Association Trainee. (Printed Name) (Signed Name) (Date) MAIL COMPLETED APPLICATION AND ALL ATTACHEMENTS TO: Southeast Alaska Pilots Association 1621 Tongass Avenue; Suite 300 Ketchikan, Alaska SEAPA Application Form

6 Directions: Candidates will assess themselves by circling the points that reflect their various experiences. Total all points in the point summary section. Provide documentation for all points claimed. Acceptable documentation includes discharges and letters from the senior management of your company or pilot association. Submit this form with the Trainee Selection Application. SOUTHEAST ALASKA PILOT S ASSOCIATION TRAINEE CANDIDATE MARITIME EXPERIENCE EVALUATION TOTAL MAXIMUM POINTS = 115 PILOTING EXPERIENCE (not to exceed a maximum of 30 pts) 100 to to 500 Over 500 movements movements movements Served as fully licensed pilot in the United States or its territories, not a member if the crew, directing and controlling the movement of vessels of not less than 1600 gross tons (minimum one hundred movements) in waters in which a pilot is required by state or federal law. 10 pts 10 pts 10 pts DEEP DRAFT EXPERIENCE (not to exceed a maximum of 25pts) 1 to 2 Over 2 up Over 5 years to 5 years years Master/Command Experience on self-propelled vessels not less than 1600 GRT or 3000 ITC or U.S. commissioned vessels not less than 200 feet length over all. 5 pts 5 pts 5 pts Chief Mate/Staff Captain/Executive Officer Experience (while holding a USCG license of at least Master ngt 1600 GT) on self-propelled vessels not less than 1600 GRT or 3000 ITC or U.S. commissioned vessels not less than 200 feet length over all. 0 pts 5 pts 0 pts Any Master/Command Experience on self-propelled vessels not less than GRT (minimum one year, not included with any other experience). 5 pts Over 2 up Over 5 TUG & TOW VESSEL EXPERIENCE (not to exceed maximum 25 pts) 1 to 2 years to 5 years years Master/Command Experience on Tugs conducting ship assist work. 0 pts 5 pts 0 pts Master/Command Experience on Tugs with Town combined tonnage greater than 1600 GRT (minimum one year not included with any other experience). 5 pts 5 pts 5 pts Chief Mate/Second-in-Command Experience on Tugs with Tows combined tonnage greater than 1600 GRT (minimum one year not included with any other experience). 0 pts 5 pts 0 pts ALASKA EXPERIENCE (not to exceed a maximum of 20 pts) 1 to 5 years Over 5 years Master/Command Experience in Alaska (minimum one year). 5 pts 5 pts Any SEAK Full Core SEAK Federal Pilotage Federal Pilotage Endorsement of First-Class pilotage without tonnage restrictions for Southeast Alaska. 2 pts 8 pts Over 2 yrs RECENCY OF EXPERIENCE (not to exceed a maximum of 15 pts) 1 to 2 yrs to 4 yrs Over 4 yrs w/in the w/in the w/in the Any of the above experience that is within the 7 years immediately previous 7 yrs previous 7 yrs previous 7 yrs Preceding the application (differing experience w/in the allowable Timeframe is cumulative). 5 pts 5 pts 5 pts POINT SUMMARY: Piloting Experience total (not to exceed a maximum of 30 pts): Deep Draft Experience (not to exceed a maximum of 25 pts): Tug & Tow Vessel Experience (not to exceed a maximum of 25 pts): Alaska Experience (not to exceed a maximum of 20 pts): Recency of Experience (not to exceed a maximum of 15 pts): TOTAL POINTS: points