Petro-Chem Services

Name*

First

Last

Email*

Phone*

Phone Alternate

Address*

Street Address City State / Province / Region Postal / Zip Code

Have you applied for a job with us before? *

When will you be able to start? (mm/dd/yy)*

Desired Salary

$

How did you hear about us? *

Referral/Other

Are you 18 years of age or older? *

Do you hold a valid and current U.S. Coast Guard Merchant Mariner Credential? *

If yes, what grade?

What is your USCG MMC original issue date? (mm/dd/yy)*

USCG MMC Number*

Have you had any spills?*

If Yes, Explain.

What is your highest level of education completed? *

Do you hold a valid and current TWIC? *

TWIC Expiration Date (mm/dd/yy)

All PCS Tankerman must carry a valid diver license and auto insurance. Do you have a valid driver license and auto insurance? *

Do you have dependable transportation? *

State Issued*

Driver License Number*

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.

Recent or current employer:*

What were your dates of employment? (mm/dd/yy)*

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.

List your previous employment:

What were your dates of employment? (mm/dd/yy)

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

Provide supervisors name and phone number.

List your previous Employer

What was your dates of employment? (mm/dd/yy)

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

Provide supervisors name and phone number:

List any personal references with phone numbers:

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 faciilities? *

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 an 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

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