Petro-Chem Services

First Name:

Last Name:

Primary Phone Number:

Alternate Phone Number:

Email Address:

Email

Confirm Email

Address:

Address Line 1

City

State

Zip Code

Have you applied for a job with us before?

When will you be able to start?

Desired Salary:

How did you hear about us?

Referral/Other

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Are you 18 years of age or older?

Do you hold a valid and current TWIC?

Do you hold a valid and current United States Coast Guard Merchant Mariner Credential (MMC) ?

If yes, what grade?

USCG MMC Number:

What is your USCG MMC original issue date?

Have you had any spills?

If Yes, Explain.

What is your highest level of education completed?

Have you ever received any training in any of the following? (select all that apply)

Do you have experience in the following cargo transfers? (select all that apply)

Do you have a valid driver's license and auto insurance?

Do you have dependable transportation?

Driver License Number

State Issued

Have you been convicted of, or have you pleaded guilty or no contest to a felony offense during the past ten years?

If yes, explain.

Employment History:

Recent or current employer:

Starting Date:

Ending Date:

What was your most recent job title/position held and a brief description of duties:

What was your reason for leaving your last employer? If you are still employed, why are you considering leaving?

Provide your current/past supervisor's name and phone number.

Employer:

Starting Date:

Ending Date:

What was your most recent job title/position held and a brief description of duties:

What was your reason for leaving this employer?

Provide your current/past supervisor's name and phone number.

Employer:

Starting Date:

Ending Date:

What was your most recent job title/position held and a brief description of duties:

What was your reason for leaving this employer?

Provide your current/past supervisor's name and phone number.

List any personal references with phone numbers:

Name:

Phone:

Name:

Phone:

Name:

Phone:

I authorize Petro-Chem Services to contact all my employment references and personal references, as well as the educational institutions I have attended. I further authorize Petro-Chem Services to inquire about investigate and obtain copies of any records which relate to me from my former employers and educational institutions.

I agree

Are you restricted from any facilities?

If Yes, Explain:

Are you restricted from any company's or boats?

If Yes, Explain:

In the past 2 years have you refused to submit to a DOT drug and alcohol test?

In the past 2 years, have you tested positive on any DOT drug or alcohol test?

If you answered yes to any of the questions in this section, can you provide documentation of successfully completing a return to duty process?

I have read and fully understand the questions asked in the application. I certify that all of the answers I have given are true, accurate and complete. I understand that the omission and/or misrepresentation of any fact from or on this application or during any interview will result in immediate rejection of my application or, if i am hired, will result in immediate dismissal.

I agree

This application for employment shall be considered active for a period of no more than 60 days. Any applicant wishing to be considered for employment beyond this time, must submit a new application. I herby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Petro-Chem Services is of an "at will" nature, which means that the Employee may resign at any time and Petro-Chem Services may discharge the Employee at any time with or without cause.

I agree

Additional Comments or Information:

Please use this space to include any additional information that you think is important for your application, or to elaborate on any answers given above. This could include clarifications, special circumstances, or any other comments that you believe will support your application.

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