Crosby Tugs Application Form – Fill Out and Use This PDF

Crosby Tugs, LLC

Application for Employment

Equal Opportunity Employer

Failure to Answer These Questions Truthfully May Result in Forfeiture of Worker’s Compensation Benefits UNDER R.S. 23:1208.1

Revision June 2019

Page 1 of 10

CTL

Application for Employment

Failure to Answer These Questions Truthfully May Result in Forfeiture of Worker’s Compensation Benefits Under R.S. 23:1208.1

APPLICANT ACKNOWLEDGEMENT OF TERMS AND CONDITIONS OF APPLICATION

IT IS VERY IMPORTANT THAT YOU READ THIS SECTION CAREFULLY, AND THAT YOU FULLY UNDERSTAND IT BEFORE YOU SIGN IT.THIS SECTION AFFECTS YOUR LEGAL RIGHTS. IF YOU HAVE ANY QUESTIONS, PLEASE ASK A CROSBY TUGS REPRESENTITIVE BEFORE YOU SIGN THIS APPLICATION.

In exchange for Crosby Tugs, LLC consideration of this employment application:

1.All information I have supplied in this application and any other form, oral or written, is true and accurate, and I agree that any misstated, misleading, incomplete, or false information is grounds for rejection and destruction of this application form, refusal to hire, withdrawal of an offer of employment, or immediate discharge without recourse, whenever and however discovered. I make this promise because I understand that you will rely on my statements to you in making your decision whether to hire me.

2.I understand and agree that Crosby Tugs, LLC and any agent acting on their behalf, as well as any other person responding to a reference request pursuant to this application, can and will seek and/or disclose any and all information about me which said corporation, agent, or person may have. I specifically authorize said disclosure and agree to hold all such corporations, agents or persons harmless for same. That is, I will not file a lawsuit, claim or charge against them for disclosure. Nor will I threaten same or otherwise seek any kind of compensation for such disclosure.

3.I certify that Crosby Tugs, LLC has my permission to implement any screening procedures that the company deems necessary. I understand that all the information obtained from such screening procedures will be used in determining my qualification for employment.

4.I understand that I can request from Crosby Tugs, LLC a copy of Crosby Tugs, LLC employee handbook, and that if I so desire, I can review said handbook before I submit this employment application (In-house Viewing). I agree to abide by the terms and conditions of all Crosby Tugs, LLC rules and regulations, including without limitation: the requirements that any accident, or any injury, no matter how minor, be immediately reported to supervision.

5.In the event that I am employed by Crosby Tugs, LLC I agree to abide by all of its policies, procedures, rules, and regulations, and agree not to disclose any confidential information regarding operating, trade secrets or personal information.

6.I understand that this form does not indicate there are positions open and does not in any way obligate Crosby Tugs, LLC to the applicant. If further understand that any such future employment is terminable by either party at will or without notice or cause. No person other than the president of Crosby Tugs, LLC may modify or amend the provisions stated herein.

7.I specifically authorize Crosby Tugs, LLC to investigate my background, including any and all references available, criminal and other judicial records, and my credit record, where applicable to the position for which I am applying and consistent with applicable law. I understand that Crosby Tugs, LLC will notify me when a credit record investigation is performed, and the sources investigated. I authorize Crosby Tugs, LLC to use all legal means at its disposal to assess my suitability for employment. I make this authorization in return for Crosby Tugs, LLC consideration of me for employment, and I specifically release and hold Crosby Tugs, LLC harmless for any and all liabilities arising out of their investigation of my application for employment.

8.I understand and agree that work schedules and requirements may vary and be unpredictable, and that, while Crosby Tugs, LLC will make reasonable efforts to accommodate work schedules and employee availability, I may be required to work overtime, weekends, different shifts, or other arrangements. I understand and agree to working up to 12 hours (either consecutive or otherwise) in a 24 hour period. I consent to these requirements as necessary and legitimate conditions of employment.

9.I hereby acknowledge that I have read and fully understand the above and hereby state that I will abide by any procedures and policies of Crosby Tugs, LLC and any falsifications or misrepresentation on this application shall be cause for immediate dismissal

__________________________________________________	____________________________________
Name (Please Print)	Date
__________________________________________________	____________________________________
Signature	Social Security Number

Revision June 2019

Page 2 of 10

CTL

Training Skills & Other Qualifications

(Please check only those that apply to you & Please provide copies of documents, and training certifications)

Captains License (Tonnage) __________________________						Mates License (Tonnage) ____________________________
Engineer (Type of License) _______________________________							Z-Card (Endorsements)___________________________
GMDSS	FCC Radio	Radar	First Aid/CPR		Basic Fire Fighting Water Survival			Vessel Security	Tankerman
STCW 95	Safe Gulf	Personal Safety		Rigger	TWIC		Other________________________________________

What else should we know about your qualifications for the job? _____________________________________________________

________________________________________________________________________________________________________

Who referred you to Crosby Tugs, LLC/How did you learn about us?

Crosby Tug Employee __________________________________ Friend/Relative ____________________________________

Newspaper ______________________ Magazine _____________________ Other __________________________________

Education & Training

	School Level	School Name & Location	Grade	Year	Courses	Degree
			Completed	Completed	Majored In	Acquired
	Grade School
	High School
	College
	Other
	Training

DRUG TESTING

I understand that Crosby Tugs, LLC has in place a drug testing policy under which I will be required to submit to a drug test as a condition of my employment, and, if employed, to submit to random drug tests as a condition of my continued employment. I give Crosby Tugs, LLC my full consent to do a drug screen and alcohol test in the event of an accident.

Signature___________________________________________________ Date:____________________________________

The following information needs to be filled out if this application has been completed by a person other than the applicant. I attest, under penalty of perjury, that I have assisted in the completion of this application and that to the best of my knowledge the information is true and correct.

____________________________________________ _____________________________________________ ____________

Preparer and/or Translator SignaturePrint NameDate

Address: ________________________________________________________________________________________________

________________________________________________________________________________________________________

City

State

Zip

Revision June 2019

Page 4 of 10

CTL

Reminder: List all jobs starting with your current/most recent employer. Please fill in all blanks completely. Do not leave gaps of employment. Please list all of your employment history regardless of whether or not it is related to the marine industry. Any gaps of employment will be questioned.

6.Employer Name_____________________________________________ Phone_______________________________

City and State_______________________________________________ Hire Date____________________________

Position____________________________________________________ Release Date_________________________

Supervisor’s Name___________________________________________ Starting Pay________ Final Pay_________

Type of Work Performed______________________________________________________________________________

Reason for Leaving__________________________________________________________________________________

7.Employer Name_____________________________________________ Phone_______________________________

City and State_______________________________________________ Hire Date____________________________

Position____________________________________________________ Release Date_________________________

Supervisor’s Name___________________________________________ Starting Pay________ Final Pay_________

Type of Work Performed______________________________________________________________________________

Reason for Leaving__________________________________________________________________________________

8.Employer Name_____________________________________________ Phone_______________________________

City and State_______________________________________________ Hire Date____________________________

Position____________________________________________________ Release Date_________________________

Supervisor’s Name___________________________________________ Starting Pay________ Final Pay_________

Type of Work Performed______________________________________________________________________________

Reason for Leaving__________________________________________________________________________________

9.Employer Name_____________________________________________ Phone_______________________________

City and State_______________________________________________ Hire Date____________________________

Position____________________________________________________ Release Date_________________________

Supervisor’s Name___________________________________________ Starting Pay________ Final Pay_________

Type of Work Performed______________________________________________________________________________

Reason for Leaving__________________________________________________________________________________

Please Explain Any Gaps of Employment

1.Date From_______________ Date To_______________

Reason for Unemployment __________________________________________________________________________

________________________________________________________________________________________________

2.Date From_______________ Date To_______________

Reason for Unemployment ________________________________________________________________________________

________________________________________________________________________________________________________

3.Date From_______________ Date To_______________

Reason for Unemployment ________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Revision June 2019

Page 6 of 10

CTL

ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK

I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and

certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Crosby Tugs, LLC at any time after

receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by DISA Global Solutions, Inc., 10900 Corporate Centre Drive, Suite 250, Houston, Texas 77041, 800752-6432, www.disa.com, and/or

Company. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be

as valid as the original.

New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law

New York City applicants only: By signing this form, you further authorize the Company to provide you with a copy of your consumer report, the New York City Fair Chance Act Notice form, and any other documents, to the extent required by law, at the mailing address and/or email address you provide to the Company.

Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company. □

Printed Name: ___________________________________________________

Signature: ______________________________________________Date: _______________________

Revision June 2019

Page 7 of 10

CTL

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Crosby Tugs, LLC may obtain information about you from a third-party consumer reporting agency for

employment purposes. Thus, you may be the subject of a “consumer report” which may include

information about your character, general reputation, personal characteristics, and/or mode of living.

These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment

history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying.

You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by DISA Global Solutions Inc., 10900 Corporate Centre Drive, Suite 250, Houston, TX 77041, 800-752-6432, www.DISA.com. The scope of this disclosure is all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports throughout the course of your employment to the extent permitted by law.

Printed Name: ________________________________________________________

Signature: _____________________________________________ Date: _________________

Revision June 2019

Page 8 of 10

CTL

DISCLOSURE FOR INVESTIGATIVE CONSUMER REPORT

Crosby Tugs, LLC may request an investigative consumer report about you from a third-party consumer

reporting agency, in connection with your employment or application for employment (including independent contractor or volunteer assignments, as applicable). !n “investigative consumer report” is a

background report that includes information from personal interviews (except in California, where that term includes background reports with or without information obtained from personal interviews). The most common form of an investigative consumer report in connection with your employment is a reference check through personal interviews with sources such as your former employers and associates, and other information sources. The investigative consumer report may contain information concerning your character, general reputation, personal characteristics, or mode of living. You may request more information about the nature and scope of an investigative consumer report, if any, by contacting the Company.

These reports will be obtained by DISA Global Solutions, Inc., 10900 Corporate Centre Drive, Suite 250,

Houston, Texas 77041, 800-752-6432, www.disa.com.

Printed Name: ________________________________________________________

Signature: __________________________________________ Date:_____________________________

Revision June 2019

Page 9 of 10

CTL

BACKGROUND INFORMATION

****ALL INFORMATION NEEDS TO BE FILLED OUT COMPLETELY***

Last Name_______________________________ First_______________________ Middle_________________

Other Names/Alias ___________________________________________________________________________

Social Security* # ____________________________________ Date of Birth* ____________________________

Driver’s License # ___________________________________ State of Driver’s License** __________________

Present Address _________________________________________ Phone Number _______________________

City/State/Zip _______________________________________________________________________________

Former Employer _________________________ Position _______________ Dates of Employment __________

By signing this form I hereby authorize, without reservation, any law enforcement agency, institution, information service, bureau, school, employer, reference, insurance company, or any other source contacted by DISA or its agent, to furnish the information described in Section 1. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports I acknowledge that I have read and understood the Employee Screening Release Authorization form. I understand that if hired my consent will apply throughout the term of my employment.

Signature: _______________________________________Date:___________________________

*This information will be used for background screening purposes only and will not be used as hiring criteria.

Revision June 2019

Page 10 of 10

CTL