Personal Data First Name * MI Last Name * E-Mail Address Street Street 2 City State Zip Home Phone Cell Phone Best Time to Call Emergency Contact Emergency Phone Other Information List any relatives currently employed by the company Have you ever been convicted of a crime? YesNo If "Yes", list convictions that are of public record (arrests are not convictions). A conviction will not necessarily disqualify you from employment. Are you lawfully able to work in this country? YesNo Do you have reasonable accommodations to get to work? YesNo Are you 18 years of age or older? YesNo Employment Information Position Applying for: [customlist position-applying size:20] Shift Desired: Full TimePart TimeOther If Other... Identify days and hours you are not available or prefer not to work: Weekends? YesNo Holidays? YesNo Employment History [field_group employment id="employment-groups" tabindex:1] Employer Name and Title of Supervisor Phone Address City State Zip Job Title Dates Employed From: To: Salary Information Starting: Ending: Summary of Job Duties Reason for leaving [/field_group] Account for any time gaps in your work history: Have you ever been terminated involuntarily from a job? YesNo Explain Company Military Service Have you served in the U.S. Military Service? YesNo Branch Date From: To: Were you honorably discharge? YesNo Please Explain Education [field_group education id="education-groups" tabindex:2] School Name Address-City-State Last Year ---9101112GED Degree ---YesNo Major or Course of Study [/field_group] Skills: Please list technical, clerical and trade skills ie: Deckhand, Welder, Equipment Operator, USCG Western Rivers Pilots license, Tankerman PIC, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert). References Name/Occupation Address/City-State-Zip Work Phone Home Phone Name/Occupation Address/City-State-Zip Work Phone Home Phone Screening History During the past two (2) years, have you tested positive, or refused to test, on any pre-employment drug or alcohol test administered by an employer to whom you applied for, but did not obtain, safety-sensitive transportation work covered by DOT drug and alcohol testing rules: YesNo If marking Yes please complete the information below: Company Name Address Phone Date and Type of Violation If you have violated any of the above DOT drug and alcohol regulations, can you provide documentation of the successful completion of DOT return to duty requirements? YesNo Applicant’s Statement and Release: (Please read carefully and sign below) I promise that the information provided in this application is true and complete. I agree that the Company may make an investigation of all statements contained in this application for employment and I understand that any false or misleading statements or omissions that I make, whether intentional or unintentional, are cause for refusal to hire or termination from employment with the Company, if I am already employed, regardless of when the false or misleading statements or omissions are discovered. I authorize former and present employers, except as I have otherwise indicated in writing to the Company’s Human Resources Manager, to provide or verify any information they have regarding me or my employment with them to a representative of the Company, and I release from any and all liability all of the above people and organizations who furnish information to the Company about my employment history. I authorize the Company to make an investigation about my educational background and also to run a criminal background investigation about me. I agree and understand that if I am hired, my employment is for no definite period of time, that I have no employment contract either written or verbal and I will be employed at will. I understand that if employed my work schedule and assigned hours may change due to the Company’s needs and agree to accept such changes as a condition of employment. I agree that if hired, I will learn about the Company’s policies and I understand that these policies may be established and changed. I agree to protect the confidence and privacy or any and all information which pertains to the conduct of the Company’s business. I promise that if I believe I am being sexually harassed or discriminated against or if I seen another worker being sexually harassed or discriminated against while working for the Company, regardless of the location, I will immediately tell Bob Aldrich, the Company’s president, about this violation of Company policy. I understand to make this report I may call Mr. Aldrich at (812) 424-9278. I understand the Company is a drug free workplace and I agree to take a pre-employment drug test as a condition of being hired, if I receive a job offer. I understand that, should I refuse to submit to a drug test, any conditional offer of employment made to me will be revoked. I also understand that if I am hired, I am required to abide by all of the Company’s rules, regulations and personnel policies. If I am applying for a job to perform “safety sensitive duties” [like but not limited to Wheelman, Tankerman and Deckhand], I understand that under federal regulation, 49 CFR 40.25, Evansville Marine Service, Inc. is required to ask my previous DOT regulated employers, whom I have worked for during the two (2) year period before the date I complete this application, if I have violated any of the DOT’s drug and alcohol standards described below: 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 agency drug and alcohol testing regulations; and With respect to any employee who violated a DOT drug and alcohol regulation, documentation of the employee’s successful completion of DOT return-to-duty requirements (including follow-up tests). If the previous employer does not have information about the return-to-duty process (e.g., an employer who did not hire an employee who tested positive on a pre-employment test), you must seek to obtain this information from the employee. If you have successfully completed DOT return-to-duty requirements (including follow-up tests) and your previous employer does not have information about the return-to-duty process we will ask you to tell us about your successful completion. I hereby authorize Evansville Marine Service, Inc. to obtain this information from previous employers and their substance abuse professionals, rehabilitation facilities, and medical review officers and I release from any and all liability all of the above people and organizations. I also authorize these previous employers and their substance abuse professionals, rehabilitation facilities and medical review officers to have oral communications with Evansville Marine Service, Inc. regarding this information.