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Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth MM DD YYYY Social Security Number Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name and Relationship Emergency Contact Number (###) ### #### EDUCATION High School/GED School Attended Start Date MM DD YYYY End Date MM DD YYYY Other Other education Trade School/College School Attended Start Date MM DD YYYY End Date MM DD YYYY Are you able to read and write in English? * Yes No Are you legally eligible for employment in the United States? * Yes No LICENSES AND CERTIFICATIONS Do you have a USCG Captain's License? * Yes No Do you have a towing endorsement? * Yes No Please check the boxes below with any safety certifications you may have. * If you have other certifications, please list them in the "Other" section below Safegulf Riggers First Aid Bloodborne Pathogens Hazard Communication H2S PPE Other EXPERIENCE Vessels Please list any vessels you have experience on Vessel Type(s) Vessel Size(s) Did you work inshore, near coastal, or offshore? Inshore Near Coastal Offshore Duties performed on vessel(s): Years of Experience: * HJ MARINE CONDUCTS CRIMINAL BACKGROUND INVESTIGATIONS ON ALL POTENTIAL EMPLOYEES Have you ever plead guilty to or have been convicted of a felony(s) or misdemeanor(s) which has not been expunged (removed) from the courts? * Yes No If you answered "Yes", please explain: Would you have a problem with us contacting your previous employer? * Yes No If you answered "Yes", please explain: PREVIOUS EMPLOYERS Name Name of Previous Employer Start Date MM DD YYYY End Date MM DD YYYY Position Held Supervisor Name of your previous supervisor Phone Number Country (###) ### #### Pay Please indicate whether hourly, monthly, salary, etc. May we contact this employer? Yes No Name Name of Previous Employer #2 Start Date MM DD YYYY End Date MM DD YYYY Position Held Supervisor Name of your previous supervisor Pay Please indicate whether hourly, monthly, salary, etc. May we contact this employer? Yes No Name Name of Previous Employer #3 Start Date MM DD YYYY End Date MM DD YYYY Position Held Supervisor Name of your previous supervisor Pay Please indicate whether hourly, monthly, salary, etc. May we contact this employer? Yes No REFERENCES List 3 people that you know personally or professionally who are not relatives Name * First Name Last Name Phone * Country (###) ### #### Relationship * Name * First Name Last Name Phone * Country (###) ### #### Relationship * Name * First Name Last Name Phone * Country (###) ### #### Relationship * AS PART OF OUR PROCEDURE FOR PROCESSING YOUR EMPLOYMENT APPLICATION, YOUR PERSONAL AND EMPLOYMENT REFERENCES MAY BE CHECKED. IF YOU HAVE MISREPRESENTED OR OMITTED ANY FACTS ON THIS APPLICATION, AND ARE SUBSEQUENTLY HIRED, YOU MAY BE DISCHARGED FROM YOUR POSITION. YOU MAY MAKE A WRITTEN REQUEST FOR INFORMATION DERIVED FROM THE CHECKING OF YOUR REFERENCES. FOR EMPLOYMENT REASONS, YOU MAY BE REQUIRED TO: SUPPLY YOUR BIRTH CERTIFICATE OR OTHER PROOF OF AUTHORIZATION TO WORK IN THE UNITED STATES, TAKE A PHYSICAL EXAMINATION AND A DRUG SCREEN BY URINE AND HAIR, AND SUBMIT TO AN ALCOHOL BREATH TEST Printed Signature of Applicant: * First Name Last Name Date MM DD YYYY INSTRUCTIONS: READ EACH PARAGRAPH AND IF YOU UNDERSTAND AND HAVE NO QUESTIONS, CHECK THE INDICATED BOX H&J MARINE LLC, PROVIDES EQUAL EMPLOYMENT OPPORTUNITY (EEO) TO ALL EMPLOYEES AND APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RAVE, RELIGION, COLOR, SEX, AGE, NATIONAL ORIGIN, DISABILITY STATUS, PREGNANCY, MARITAL STATUS, SEXUAL ORIENTATION, CITIZENSHIP STATUS, VETERAN/MILITARY STATUS OR ANY OTHER LEGALLY PROTECTED CATEGORY AND/OR CHARACTERISTIC * I understand IN THE EVENT I BECOME EMPLOYED BY H&J MARINE LLC, I ACKNOWLEDGE AND UNDERSTAND MY EMPLOYMENT IS “AT WILL”, I FURTHER UNDERSTAND THAT EITHER I OR H&J MARINE LLC MAY TERMINATE MY EMPLOYMENT FOR ANY REASON, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE * I understand I UNDERSTAND THAT EVEN THOUGH I MAY BE SENT FOR A PHYSICAL AND DRUG SCREEN DOES NOT GUARANTEE THAT I WILL BE HIRED BY H&J MARINE. I UNDERSTAND THAT THE FINAL DECISION FOR HIRE WILL COME AFTER I TAKE A PHYSICAL AND DRUG SCREEN AND MY CRIMINAL BACKGROUND CHECK HAS BEEN COMPLETED * I understand I UNDERSTAND AND AGREE THAT IF I SHOULD QUIT OR BE FIRED WITHIN THE FIRST SIXTY DAYS OF EMPLOYMENT, THE COST OF MY PRE-EMPLOYMENT PHYSICAL AND DRUG TEST WILL BE DEDUCTED FROM MY FINAL PAYCHECK. * I understand I ACKNOWLEDGE AND AGREE THAT ANY FALSE OR MISLEADING INFORMATION PROVIDED OR OMITTED ON THE EMPLOYMENT APPLICATION OR DURING THE PRE-EMPLOYMENT PROCESS MAY RESULT IN RETRACTION OF THE EMPLOYMENT OFFER OR IMMEDIATE TERMINATION OF EMPLOYMENT * I understand I UNDERSTAND THAT I WILL BE REQUIRED TO PRODUCE PROOF OF MY IDENTITY AND LEGAL RIGHT TO WORK IN THE UNITED STATES UPON SELECTION AND ACCEPTANCE FOR EMPLOYMENT * I understand I UNDERSTAND AND AGREE THAT ANY AND/OR ALL OF THE INFORMATION INCLUDED IN THIS APPLICATION IS SUBJECT TO VERIFICATION. I AUTHORIZE PREVIOUS EMPLOYERS, LSITED REFERENCES, AGENCIES, AND CREDENTIALING BODIES TO RELEASE INFORMATION TO H&J MARINE LLC RELATED TO MY EMPLOYMENT, CREDENTIALS, AND ABILITIES. I FURTHER AGREE TO HOLD HARMLESS ANY AND ALL INDIVIDUALS, COMPANIES, AGENCIES, AND EDUCATIONAL FACILITIES THAT PROVIDE ANY FACTUAL INFORMATION AND/OR DOCUMENTATION, AS RELATED TO THIS APPLICATION FOR EMPLOYMENT * I understand Printed Signature of Applicant * First Name Last Name CONSENT FOR ALCHOL/DRUG SCREENING * I HEREBY GIVE MY CONSENT TO H&J MARINE, LLC AND/OR ITS AGENTS/REPRESENTATIVES TO COLLECT URINE, BLOOD AND HAIR OR BREATH SAMPLES FROM ME FOR THE PURPOSE OF TESTING TO DETERMINE THE PRESENCE OF ALCOHOL, DRUGS AND/OR ANY CONTROLLED SUBSTANCES AS DEFINED H&J MARINE'S ANTI-SUBSTANCE ABUSE POLICY, GUIDELINES AND/OR OTHER PRACTICES/PROCESSES RELATED TO THE ELIMINATION OF SUBSTANCE ABUSE IN THE WORKPLACE * I UNDERSTAND I WILL BE TESTED FOR THE FOLLOWING DRUGS: AMPHETAMINES EXTENDED, AMPHETAMINE, MDMA MDA MDEA, BENZOLECGONINE (COCAINE), OPIATES (MORPHINE), PHENCYCLIDINE, TETRAHYDROCANNABINOL MARIJUANA, 6-ACETYLMORPHINE, HEROIN, METHANPHETAMINE "ECSTASY", ADDITIONAL DRUGS MAY BE ADDED, FROM TIME TO TIME IN ORDER TO COMPLY WITH REQUIREMENTS OF H&J MARINE'S CLIENTS DRUG TESTING POLICY. CUT OFF LIMITS MAY BE CHANGED BY FUTURE REGULATION. * ANY INDIVIDUAL, WHETHER EMPLOYEE OR PRE-EMPLOYEE THAT FAILS A CHEMICAL TEST FOR DANGERS, H&J MARINE WILL REPORT THE TEST RESULTS IN WRITING TO THE NEAREST COAST GUARD OFFICER IN CHARGE. THAT INDIVIDUAL WILL BE DENIED EMPLOYMENT AS A CREW MEMBER AND REMOVED FROM DUTIES WHICH DIRECTLY AFFECT THE SAFTEY OF THE VESSEL'S NAVIGATION OR OPERATIONS AS SOON AS PRACTICABLE. * I FURTHER GIVE MY CONSENT FOR THE RELEASE OF ANY AND ALL TEST RESULTS TO THOSE ENTITIES AND/OR PERSONS DEEMED BY H&J MARINE TO HAVE A NEED TO ACCESS SUCH RESULTS. I FURTHER ACKNOWLEDGE AND AGREE THAT SUCH RESULTS MAY BE DISCLOSED TO AUTHORIZED MEMBERS OF H&J MARINE'S MANAGEMENT AND/OR CUSTOMER ENTITIES AS REQUIRED AND SUCH RESULTS WILL BE CONSIDERED IN DETERMINING MY EMPLOYMENT WITH H&J MARINE, LLC * I ACKNOWLEDGE AND UNDERSTAND THAT MY REFUSAL TO SUBMIT TO A DRUG AND/OR ALCOHOL TEST, FALSIFICATION OF A TEST, TAMPERING WITH A SAMPLE OR TEST, OR TESTING POSITIVE ON A TEST CAN AND WILL RESULT IN RETRACTION OF THE EMPLOYMENT OFFER OR IMMEDIATE TERMINATION OF EMPLOYMENT. Printed Signature of Applicant: * First Name Last Name Date MM DD YYYY AUTHORIZATION TO OBTAIN REPORTS * I HEREBY AUTHORIZE H&J MARINE TO OBTAIN REPORTS THAT INCLUDE MOTOR VEHICLE REPORTS, CRIMINAL REPORTS,EDUCATION, PRIOR EMPLOYER VERIFICATION, WORKERS COMPENSATION CLAIMS REGARDING ME IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT OR IF HIRED, COULD FORM THE BASIS FOR A DECISION BY THE COMPANY NOT TO EMPLOY ME, AND I HEREBY RELEASE THE COMPANY, ITS DIRECTORS, OFFICERS, AGENTS, EMPLOYEES, AND INSURERS, AS WELL AS THE PROVIDER OF THE REPORTS FROM ANY AND ALL CLAIMS ARISING OUT OF OR RELATING TO THE DECISION NOT TO EMPLOY ME NOTE: THIS INFORMATION IS USED FOR THE SOLE PURPOSE OF OBTAINING MOTOR VEHICLE REPORTS, CRIMINAL REPORTS, EDUCATION, PRIOR EMPLOYMENT VERIFICATION, WORKERS COMPENSATION CLAIMS THIS INFORMATION IS USED STRICTLY FOR EMPLOYMENT PURPOSES. H&J MARINE PROVIDES EQUAL EMPLOYMENT OPPORTUNITIES TO ALL EMPLOYEES AND APPLICANTS WITHOUT REGARD TO RACE, RELIGION, COLOR, SEX, AGE, NATIONAL ORIGIN, DISABLILITY STATUS, PREGNANCY, MARITAL STATUS, SEXUAL ORIENTATION, CITIZENSHIP STATUS, VETERAN/MILITARY STATUS OR ANY OTHER LEGALLY PROTECTED CATEGORY AND/OR CHARACTERISTIC. H&J MARINE, LLC DOES NOT SHARE THIS INFORMATION WITH ANYONE OR ANY COMPANY. THIS INFORMATION IS USED STRICTLY FOR EMPLOYMENT PURPOSES. Print Legal Name * First Name Last Name Date of Birth * MM DD YYYY Driver's License Number * State Issued * Social Security Number * Printed Signature * First Name Last Name Date MM DD YYYY Thank you!
