Employment desired _____________________ FULL-TIME ONLY__  PART-TIME ONLY__  FULL- OR PART-TIME___  

Address ___________________________________________________________________________________ How long_______________

Social Security No. _______ – _____ – _________  Telephone (_____________) Cell phone (____________)  Birth Date _________________

Emergency Contact  Name _____________________Telephone (_____________) Cell phone (____________) Address ___________________

Position applied for (1) __ ______________________Date Available _______________
Days/hours available to work No Pref _______ Mon ________ Tues ________ Wed _______ Thurs ______ Fri ______Sat _______Sun _______
How many hours can you work weekly? ____________ Can you work nights till 8:00_______

MOST RECENT TYPE OF SCHOOL_________________NAME OF SCHOOL ______________________ LOCATION ______________

NUMBER OF YEARS COMPLETED ________________ MAJOR & DEGREE ______________________

VESSELL OPERATING LICENSE AND EXPERIENCE _________________________________________________________________

_______________________________________________________________________________________________________________

HAVE YOU EVER BEEN CONVICTED OF A CRIME?__ No__ Yes
If yes, number of conviction(s), nature of offense(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

________________________________________________________________________________________________________________

DO YOU HAVE A DRIVER’S LICENSE?__ Yes __ No  What is your means of transportation to work? ______________________
Driver’s license number ____________ State of issue _______ Operator ________ Commercial (CDL) _____ Chauffeur____Expiration date __
Have you had any accidents during the past three years?____How many? ____Have you had any moving violations during the past three years?___
How Many? ___ What type of violations?________________________________________________
Please list two references other than relatives or previous employers.
Name--------------------------Position---------------------------Company-------------------Address------------------Telephone ( -------------)
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MILITARY-  HAVE YOU EVER BEEN IN THE ARMED FORCES?_____ Yes _____No

ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?_Yes _ No     Specialty _ Date Entered _ Discharge Date _

Work Experience  Please list your work experience for the past five years beginning with your most recent or current job held. 
If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of employer-----Address------Name of last supervisor-------Phone number-----Employment dates-----Your last job title----Reason for leaving
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- Use additional pages to for additional information to describe your full qualifications for the specific position for which you are applying.
May we contact your present employer?____ Yes ____ No     Past employers? _____yes_____no

Did you complete this application your self_____ Yes _____ No    If not, who did?____________

Signature __ _________________________ Date___________________

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