Blessey Employment Application

Employment Application

Applicants for VESSEL positions must possess a T.W.I.C. (Transportation Worker Identification Credential)
to be considered for employment with Blessey Marine.

ALL FIELDS MARKED WITH ASTERISK (*) ARE MANDATORY AND MUST
BE COMPLETED FOR YOUR APPLICATION TO BE ACCEPTED.

It is the policy of Blessey Marine to provide equal opportunity in employment and advancement to all persons without regard to race, color, religion, age, gender/sex, national origin, disability or any other protected status under state and federal law.

Applying for Position As *

Date Submitted

Month Day Year Hour Minutes

What position are you applying for? *

First Name *

Middle Name *

Last Name *

Suffix (Jr, Sr, III, etc..)

APPLICATIONS THAT LIST A P.O. BOX AS AN ADDRESS WILL NOT BE ACCEPTED.

Current Physical Address *

Street Address

Apartment or Suite#

City State / Province

Zip Code Country

E-Mail Address *

Social Security Number *

Driver's License Number *

Driver's License State *

Telephone 1 *

*

Cell Home Other

Telephone 2

Cell Home Other

Previous Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Are you 18 years or older? *

Yes No

Are you able to provide proof that you are legally entitled to work in the United States? *

Yes No

Do you have a valid Transportation Worker Identification Credential (TWIC) card? *

Yes No

Please give TWIC Expiration Date *

Month Day Year

Have you applied for your Transportation Worker Identification Credential (TWIC) card? *

Yes No

Can you produce documentation verifying your Transportation Worker Identification Credential (TWIC) application? *

Yes No

Do you have a valid Merchant Mariner Credential? *

Yes No

Please give Merchant Mariner Expiration Date *

Month Day Year

Are you Currently employed *

Yes No

Who referred you to us? *

Have you applied with Blessey Marine before? *

Yes No

Please give date of application *

Month Day Year

Have you ever worked for Blessey Marine before? *

Yes No

Please give last date of employment *

Month Day Year

Can you travel if your assignment requires it? *

Yes No

Are you available to work overtime or over 40 hours per week? *

Yes No

On what date would you be available for work? *

Month Day Year

Note: An individual will not be denied employment solely because of a felony or misdemeanor conviction, but all circumstances must be considered.

Have you ever been convicted of a felony or misdemeanor? *

Yes No

Please give the date of said conviction. *

Month Day Year

Please give the circumstances and details involving said conviction *

Employment Experience

Please list the name of your present and all previous employers in chronological order. If you have been self-employed, or are currently self-employed, please give the name of your firm, company or operations.

If you have previous work experience you MUST supply your previous employer's information *

I have NO previous work experience Add previous work experience

1.) Employer Name

Name of supervisor

Telephone #

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Employed From

Month Day Year

To

Month Day Year

Job Title

Describe your work

Reason for leaving

Starting Wage

Ending Wage

2.) Employer Name

Name of supervisor

Telephone #

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Employed From

Month Day Year

To

Month Day Year

Job Title

Describe your work

Reason for leaving

Starting Wage

Ending Wage

3.) Employer Name

Name of supervisor

Telephone #

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Employed From

Month Day Year

To

Month Day Year

Job Title

Describe your work

Reason for leaving

Starting Wage

Ending Wage

Education

Please list all schools and technical training you have received.

GED / Certificate of High School Equivalency? *

Yes No

Did you attend High School? *

Yes No

High School *

Years Completed *

9 10 11 12

Course of Study *

Diploma/Degree? *

Yes No

Did you attend College? *

Yes No

College/University *

Years Completed *

1 2 3 4

Course of Study *

Diploma/Degree? *

Yes No

Did you attend Vocational/Technical School? *

Yes No

Vocational/Technical *

Years Completed *

1 2 3 4

Course of Study *

Diploma/Degree? *

Yes No

Describe all other training, experience, skills and special educational experiences:

Describe any job-related training received in the United States military:

References

Please provide 3 personal references who are not related to you.

1.) Reference *

First Name Last Name

Telephone # *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Reference 2.) *

First Name Last Name

Telephone # *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Reference 3.) *

First Name Last Name

Telephone # *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Do you understand the requirements of the job for which you are applying? *

Yes No

Can you perform the requirements of this job with or without reasonable accommodation? *

Yes No

CERTIFICATION BY APPLICANT

I hereby authorize Blessey Marine Services, Inc. (hereinafter "Blessey Marine") and its representatives, agents, employees or designees to contact my current or any previous employer for the purpose of requesting any and all information concerning my previous employment and any pertinent information which they may have concerning my employment. I also authorize Blessey Marine and its employees, agents, representatives, and designees to investigate all statements contained in this application for employment, contained in my resume and/or provided in my job interview as may be necessary in arriving at an employment decision. I further authorize all present and former employers, along with the personal references listed in the application, to give Blessey Marine, its employees, agents, representatives and designees’ any and all information concerning my previous employment with said employers.

I understand that Blessey Marine requires certain applicants to undergo a post-offer, pre-employment physical examination and drug test as a condition of employment. I hereby give my consent to any such test or examination and consent to the release of the results of any such test or examination to Blessey Marine. I understand that information provided to Blessey Marine may be disclosed.

I understand that the submission of this application for employment to Blessey Marine does not create a promise of employment or the creation of an employment contract or a term of employment. I understand that if I become employed with Blessey Marine that any employment relationship with Blessey Marine will be of an "at-will" nature. This means that I, as an employee, have the right to resign at any time with or without cause and with or without notice, and that Blessey Marine has the right to discharge me from employment at any time with or without cause and with or without prior notice. I further understand that this "at-will" employment relationship may not be changed by anything anyone tells me or by any written document or conduct or representation unless I am provided and execute a written employment contract signed by the president of Blessey Marine.

I understand that in submitting this application that it will be considered active for no more than one year. If I intend to be considered for employment thereafter, I must reapply for a position with Blessey Marine.

I understand that false information, information that Blessey Marine considers to be misleading, or the failure to provide a complete response to any question, whether on this application or in an interview with Blessey Marine’s representative, will disqualify me from further consideration for employment. I understand also that if Blessey Marine subsequently determines, after I am hired, that I either failed to provide necessary information, provided misleading information, provided false information, this determination should be satisfactory reason for Blessey Marine to terminate my employment.

A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

* You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

* You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
* a person has taken adverse action against you because of information in your credit report;
* you are the victim of identify theft and place a fraud alert in your file;
* your file contains inaccurate information as a result of fraud;
* you are on public assistance;
* you are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.ftc.gov/credit for additional information.

* You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

* You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.ftc.gov/credit for an explanation of dispute procedures.

* Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

* Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

* Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

* You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit.

* You may limit "prescreened" offers of credit and insurance you get based on information in your credit report. Unsolicited "prescreened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

* You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

* Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:

TYPE OF BUSINESS:

Consumer reporting agencies, creditors and others
not listed below

CONTACT:

Federal Trade Commission: Consumer Response
Center - FCRA
Washington, DC 20580
1-877-382-4357

National banks, federal branches/agencies of
foreign banks (word"National" or initials "N.A."
appear in or after bank's name)

Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219
800-613-6743

Federal Reserve System member banks (except
national banks, and federal branches/agencies of
foreign banks)

Federal Reserve Consumer Help (FRCH)
P O Box 1200
Minneapolis, MN 55480
Telephone: 888-851-1920
Website Address:www.federalreserveconsumerhelp.gov
Email Address:ConsumerHelp@FederalReserve.gov

Savings associations and federally chartered
savings banks (word"Federal" or initials "F.S.B."
appear in federal institution's name)

Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 800-842-6929

Federal credit unions (words "Federal Credit
Union" appear in institution's name)

National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314
703-519-4600

State-chartered banks that are not members of the
Federal Reserve System

Federal Deposit Insurance Corporation
Consumer Response Center
2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638
877-275-3342

Air, surface, or rail common carriers regulated by
former Civil Aeronautics Board or Interstate
Commerce Commission

Department of Transportation , Office of Financial
Management
Washington, DC 20590
202-366-1306

Activities subject to the Packers and Stockyards
Act, 1921

Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250
202-720-7051

CONSENT TO PROCUREMENT OF CONSUMER CREDIT REPORT

I understand that, as a condition of my consideration for employment with Blessey Marine, or as a condition of my continued employment with Blessey Marine, the company may obtain a consumer report that includes, but is not limited to, my creditworthiness or similar characteristics, employment and education verifications, social security verification, criminal and civil history, personal interviews, DMV records, any other public records and any other information bearing on my credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness. I hereby authorize and consent to Blessey Marine procurement of such a report. I understand that, pursuant to the federal Fair Credit Reporting Act, Blessey Marine will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making a decision regarding my fitness for employment with Blessey Marine. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report.

I certify that all information stated by me in this application is true and complete. I have read and understand the foregoing statements contained in the sections entitled "Certification by Applicant","A Summary of Your Rights Under the Fair Credit Reporting Act" and "Consent to Procurement of Consumer Credit Report".

First Name *

Middle Name *

Last Name *

Suffix (Jr, Sr, III, etc..)

Initials *

Attach Resume (optional)

You must type the word displayed below in order to submit this application *