Online Employment Application Form APPLICATION FOR EMPLOYMENTANSWER ALL QUESTIONS contained in this application and any supplement forms for the position you are applying. Please print all answers legibly. Attach copies of appropriate Merchant Mariner’s Document or License with this application.Last NameFirst NameMiddle NameCurrent Address:Telephone Area Code:Telephone Number:Alternate Contact Telephone Numbers:Email Address* (Area Code)(Number)(Relationship)Position for which you are applying:Do You have a TWIC Card? Yes No Have you filed an application here before?: Yes No If Yes when?:Have you ever been employed here before?: Yes No If Yes when?:Have you been convicted of a crime (misdemeanor or felony) in the past 10 years?: Yes No If yes, please state the circumstances including where and date:Are you currently under arrest for any crime which has yet to be finalized, pending trial ?: Yes No If Yes when?:If Yes, Please state the circumstances including where and date:HAVE YOU EVER TESTED POSITIVE, OR REFUSED TO TEST, ON ANY PRE-EMPLOYMENT, REASONABLE CAUSE, RANDOM, FOLLOW-UP OR POST ACCIDENT DRUG OR ALCOHOL TEST?* Yes No (INITIALS REQUIRED BY SELECTION)By Regulations That Went Into Effect on 01 August 2001, You Must Complete the Attached Drug and Alcohol Testing Information Employee Consent and Certification Forms.Have you ever been convicted of drug or alcohol abuse?* Yes No If yes, state where, date of conviction and sentence:Are you currently on probation or parole?* Yes No If yes, are there any restrictions which would prohibit you from Interstate or Foreign travel?Has your driver’s license ever been suspended? Yes No If yes, state where, date of suspension and length, and current status:EducationGrammar School, NAME & LOCATIONGrammar School, YEARS ATTENDEDGrammar School, DATE GRADUATEDHigh School, NAME & LOCATIONHigh School, YEARS ATTENDEDHigh School, DATE GRADUATEDCollege, NAME & LOCATIONCollege, YEARS ATTENDEDCollege, DATE GRADUATEDList any trade schools or special training received, include the year(s) attended. If job related, include military experience:List employment for at least the past 10 years with last or present employer listed first:Company Name:Street Address:City and State:Telephone:Job Title:Supervisor:Dates employed:To:Salary (start):(ending)Reason for leaving:Company Name:Street address:City and State:Telephone:Job Title:Supervisor:Dates employed:To:Salary (start):(ending)Reason for leaving:Company Name:Street address:City and State:Telephone:Job Title:Supervisor:Dates employed:To:Salary (start):(ending)Job Title:Reason for leaving:Company Name:Street address:City and State:Telephone:Supervisor:Dates employed:To:Salary (start):(ending)Reason for leaving:Addresses for Last 10 Years (Must Complete)ADDRESSES FOR LAST 10 YEARSDo you have the agility, strength and flexibility to (Circle one Y/N)1.Climb steep or verticle ladders. Yes No 2. Maintain balance on a moving deck. Yes No 3. Pull heavy hoses up to 400 feet. Yes No 4. Step over door sills of 24 inches in height. Yes No 5. Open/close doors that weigh up to 56 lbs. Yes No If you have any questions about the essential job functions of the position for which you are applying, please contact the personnel manager.Please read the statements below, if you have any questions, ask before you sign and date.I understand that this application will be considered “active” for ninety (90) calendar days from the date of application. If I have not obtained employment with Cembulk Services Towing, Inc. within 90 calendar days and remain interested in obtaining employment, then I must notify Cembulk Services. in writing of my intention. I understand further that any misstatements or material omissions in this application may result in a decision not to hire, or discharge if discovered at any time after hire. If employed, I agree to conform to the rules and regulations of Cembulk Services. I also agree that, just as I have, if hired, the right to resign my employment and compensation may be terminated with or without cause, and with or without notice, at any time at the option of either myself or Cembulk Services. I understand that my employment is not for any specific period of time. I hereby represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions of my own free will and in accordance with my own judgment.Signature of ApplicantDatePre-Employment AgreementI freely and voluntarily agree to submit to urinalysis (drug screen) as part of my application for employment. I understand that either refusal to submit to the urinalysis screen or failure to qualify accordingly to the minimum standards established by the company for this screen may disqualify me from further consideration for employment. I further understand that upon commencement of employment with the company I may again be required to submit to a regular urinalysis screening. I understand that refusal to take a requested urinalysis screen may result in immediate suspension or discharge. I have read in full and understand the above statements and conditions of employment.Applicant’s SignatureDateApplicant, Please Complete and Sign the AuthorizationApplicant NamePositionCurrent AddressCity/State/ZipPrior AddressCity/State/ZipDATE OF BIRTHLAST 4-SSN NO.PROFESSIONAL LICENCE NO.TYPEDATE ISSUEDAuthorization and Release of Liability Informed Consent to Reference CheckI hereby authorize without reservation, any party or agency- contacted by this employer or agent of this company, to furnish the requested Information. I understand that an employment decision and my continued employment with Cembulk Services. may be subject to the results of these inquiries. I hereby release without reservation, any ompany or party giving or receiving any such information For any purpose related to my employment from any liability which may result of Information disclosed by Such contacts. I hereby release and forever discharge/ without reservation, Cembulk Services. (Including its dirtctors, officers, employees, Its agents, contractors and subcontractors) and my past and present employers {their diractors officers, employees, and agents) from any liabilities that may result from the verification of my employment and/or from the disclosure of any information requested by Cembulk Services.APPLICANT SIGNATUREPRINTED NAMEDATECAPTCHA