Employment Application POSITION APPLIED FOR:*CaptainRelief CaptainWheelmenTankermenCustodian USCG Reference Number*Name First Middle Last Home Phone NumberMobile Phone NumberEmail Address Social Security NumberDate of Birth MM DD YYYY *Age, sex, color. national origin, and religion are not factors in making employment decisions.HAVE YOU EVER USED ANOTHER NAME AND/OR SOCIAL SECURITY NUMBER FOR IDENTIFICATION? If so, please identify:Present Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Permanent Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country What type of Drivers License do you have? Operator Commercial Operator Class Operator NumberPlease upload a photo of your Driver's LicenseAny Restrictions on License? Yes No IF YES, EXPLAINHighest Level of EducationGrade SchoolHigh SchoolCollegeGraduate SchoolCommercialOther Other EducationARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE U.S.A.? Yes No IN CASE OF EMERGENCY NOTIFY (Name & Phone #):EMPLOYMENT HISTORY: Give Name and Address of Five Last Employers, Including Name of SupervisorsNAME OF EMPLOYER AND SUPERVISOREMPLOYER ADDRESSEMPLOYER PHONE NUMBERTYPE OF WORK DONEEmployed From MM DD YYYY To MM DD YYYY Reason For LeavingJob Number 2NAME OF EMPLOYER AND SUPERVISOREMPLOYER ADDRESSEMPLOYER PHONE NUMBERTYPE OF WORK DONEEmployed From MM DD YYYY To MM DD YYYY Reason For LeavingJob Number 3NAME OF EMPLOYER AND SUPERVISOREMPLOYER ADDRESSEMPLOYER PHONE NUMBERTYPE OF WORK DONEEmployed From MM DD YYYY To MM DD YYYY Reason For LeavingJob Number 4NAME OF EMPLOYER AND SUPERVISOREMPLOYER ADDRESSEMPLOYER PHONE NUMBERTYPE OF WORK DONEEmployed From MM DD YYYY To MM DD YYYY Reason For LeavingJob Number 5NAME OF EMPLOYER AND SUPERVISOREMPLOYER ADDRESSEMPLOYER PHONE NUMBERTYPE OF WORK DONEEmployed From MM DD YYYY To MM DD YYYY Reason For LeavingPersonal HistoryHave You Had a Physical Examination in the Past 5 Years? Yes No Do you have any physical or mental condition(s) which may interfere with or hinder the performance of the job for which you wish to be considered? If so, please explain:Have you ever had an on the job injury? Yes No If the answer is yes to proceeding question, complete below:Approximate Date of InjuryEmployer at Time of InjuryNature of InjuryWere you Disabled? Yes No Approximate Length of Time You Were Off WorkWas a Claim for Benefits Made? Yes No Will You Abide by the Safety Rules of this Company? Yes No If injured, will you accept the medical facilities recommended by your employer? Yes No Have you ever been convicted of a criminal offense (do not include parking tickets)? Yes No If the answer is yes to this question, complete below:Date of Conviction MM DD YYYY Location and Nature of ConvictionDisposition of OffenseConfidential Drug and Alcohol Testing InformationDOT Regulation 49 CFR Part 40.25 I consent and authorize my PREVIOUS EMPLOYER to furnish the following information:Name*Social Security Number*Company Name of Previous Employer*PhoneFax NumberAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country I authorize my previous employer to speak with, send documentation to, and otherwise communicate with CTCO regarding the information contained in the section below. I authorize my previous employer to release CTCO records and information relating to any completion of the DOT return-to-work process: Alcohol tests with a result of 0.04 or higher alcohol concentration. Verified positive drug tests Refusals to be tested (including verified adulterated or substituted drug test results). Other violations of DOT of agency drug and alcohol testing regulations. *SIGNATURE OF APPLICANT* MM DD YYYY DATEPLEASE READ THE FOLLOWING CAREFULLY AND SIGN BELOWI hereby declare that I am not disabled in any way which would prevent me from steadily performing all the work applied for in this application. I further declare that the answers to the questions on the opposite side are correct and that any misstatement of fact or omission should be cause for dismissal or rejection. I authorize the company to contact any of my previous employers as well as any reference source in order to verify the facts and information I have furnished regarding my qualifications and character. I hereby authorize any person(s) having knowledge thereof to provide such information to the company, and I hereby release from liability and agree to hold harmless any person that furnishes such information in good faith. I agree that I will submit to a physical, urinalysis, and/or blood or other examination requested by the company at any time prior to or subsequent to my employment. I authorize the company to supply my employment record in whole or part and in confidence to any employer insurance agency, or other party with legal and proper interest, and I hereby release the company from any liability and agree to hold harmless any employee of the company who furnishes such information. I further understand that my employment is for no fixed time and may be discontinued with or without cause or notice by myself or the company. I understand that no employee or officer or agent of the company may bind it by oral or printed statements, including handbooks, benefit books, or bulletins, contrary to the above. Finally I understand that no firearms, alcohol, or drugs are permitted on company premises, and that either being under the influence of alcohol or have identifiable traces of illicit drugs in my system during working hours is strictly prohibited. If medication is prescribed by doctor, I am required to notify management, in writing, of the specific medical problem and the exact drug that has been prescribed, immediately upon reporting to work. Under the provisions of the Fair Credit Reporting Act, 15 U.S.C. Sec. 1681, et. seq. notice is hereby given that an investigative consumer report may be made which may include information pertaining to your credit worthiness, character, general reputation, personal characteristics, and mode of living, which will be used for employment purposes. An investigation into your workers’ compensation or industrial accident background may also be conducted. You are further advised under said Act you have the right to request the company to make a complete and accurate disclosure of the nature and scope of the investigation requested by the company. Your request must be in writing and submitted within a reasonable period of time after your application. The company shall respond in writing, mailed or otherwise delivered, to you no later than five days after the date on which the request for such disclosure was received from you or such investigative consumer report was first requested by the company, whichever is the later. I have carefully read the above provisions and, having had the opportunity to ask question about them, agree to the terms printed on this form.* I have read and agree to the terms SIGNATURE OF APPLICANT MM DD YYYY DATECONSENT TO OBTAINING CONSUMER REPORTSREAD CAREFULLY BEFORE SIGNING I HAVE READ THE ATTACHED “NOTICE TO APPLICANTS/EMPLOYEES REGARDING CONSUMER REPORTS” AND HEREBY AUTHORIZE THE COMPANY TO OBTAIN CONSUMER REPORTS AND/OR INVESTIGATIVE CONSUMER REPORTS AS DESCRIBED. I UNDERSTAND THAT I HAVE THE RIGHT TO MAKE A WRITTEN REQUEST WITHIN A REASONABLE AMOUNT OF TIME TO RECEIVE ADDITIONAL, DETAILED INFORMATION ABOUT THE NATURE AND SCOPE OF ANY INVESTIGATIVE REPORT OR OTHER CONSUMER REPORTS THAT ARE MADE, INCLUDING THE NAME, ADDRESS AND TELEPHONE NUMBER OF THE CONSUMER REPORTING AGENCY. I HEREBY AUTHORIZE ANY PRESENT OR FORMER EMPLOYERS, CONSUMER REPORTING AGENCIES, EDUCATIONAL INSTITUTIONS, CRIMINAL JUSTICE AGENCIES, DEPARTMENTS OF MOTOR VEHICLES, PUBLIC AGENCY, FINANCIAL INSTITUTIONS, OR ANY OTHER PERSON OR AGENCY HAVING KNOWLEDGE OF ME TO SUBMIT INFORMATION OR OPINIONS ABOUT MYSELF, INCLUDING DATA RECEIVED FROM OTHER SOURCES, IN ORDER THAT MY EMPLOYMENT QUALIFICATIONS MAY BE EVALUATED. I HOLD SAID PERSONS AND/OR ORGANIZATIONS BLAMELESS AND WITHOUT LIABILITY FOR STATEMENTS OR OPINIONS MADE REGARDING MY CHARACTER, EXPERIENCE OR QUALIFICATIONS. BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD ALL OF THE ABOVE STATEMENTS.* I have read and agree to the terms SIGNATURE OF APPLICANT MM DD YYYY DATEEQUAL OPPORTUNITY EMPLOYER M/F/H
