Application for Employment

Name*

Date of Birth*

SS#(Last four)

Email*

Telephone*

Street Address*

City*

State*

Zip Code*

Do you have any limitations to physical activity

Yes No

If yes, provide details

Hobbies

Have you ever been convicted of a crime

Yes No

If yes, provide details

Do you have a valid driver’s license

Yes No

If so please list license number

Emergency Notification

Emergency Phone

What position are you applying for

Type of employment you are seeking

Full Time Part Time Temporary

Are you currently employed

Yes No

If so, where

Do you have a US Merchant Marine Officers License

Yes No

If so, what tonnage & routes

1. Previous Company

Dates of employment From:

To:

Duties and Responsibilities

Salary

Reason for leaving

2. Previous Company

Dates of employment From:

To:

Duties and Responsibilities

Salary

Reason for leaving

Reference Name

Reference Address

Reference Phone

Relationship

Reference Name

Reference Address

Reference Phone

Relationship

Vessel Name

Gross Tonnage

Routes

Nature of work

Position & Duties

Dates as crew From:

To:

Vessel Name

Gross Tonnage

Routes

Nature of work

Position & Duties

Dates as crew From:

To:

High School

Vocational School

College

Degrees

Please list any special job-related skills and qualifications acquired from employment of other experiences

Can you be away from home for a week or more with very little notice

Yes No

Do you have dependable transportation

Yes No

Can you splice line

Yes No

Can you tie a bowline

Yes No

What are your feelings on pitching in on any task needed to be done, not necessarily marine or vessel related, such as: oil spill clean-up work, grocery shopping for the crew, cleaning the shop or even fixing a toilet

I hereby certify that the information contained in this application is correct to the best of my knowledge and understand that, if I am employed, any misrepresentation of omission of material facts on this application, regardless of when discovered, is sufficient cause for dismissal. I understand that my employment and compensation can be terminated at any time without cause and with or without notice at any time, at the option of Miller Marine Services Inc. or myself. I understand that no one has the authority to promise permanent employment of employment for a definite period of time. The company, in considering my application for employment, may verify the information set forth in this application and obtain additional information relating to my background. I authorize all persons, schools, companies, corporations, credit bureaus, law enforcement agencies and doctors to supply any information concerning my background. Provided state law permits, I further agree to submit to alcohol and drug screening tests and polygraph examinations, if requested of me at any time prior to, or during my employment

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