Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Driver's License Expiration *

MM

DD

YYYY

Date Available to Start *

MM

DD

YYYY

If you were referred by a Dupre Marine Transportation employee, please mention their name

First Name

Last Name

Have you ever been employed by Dupre Marine Transportation? *

Yes

No

Previous Start Date at Dupre Marine

MM

DD

YYYY

Previous End Date at Dupre Marine

MM

DD

YYYY

Employment History *

Give complete record of all employment including military, and reasons for periods of unemployment during the last 10 years. List employers starting with most recent. Vessel Applicants, your marine industry employment is priority. Regulated USCG- Applicants who will be wheelmen are required to supply information on those employers for whom the applicant operated such vessels. No "See Resume" responses will be accepted.

Read and acknowledged

Is this a current employer? *

Yes

No

May we contact your current employer? *

Yes

No

Contact Person

First Name

Last Name

Company Phone # *

(###)

###

####

Start Date *

MM

DD

YYYY

End Date

MM

DD

YYYY

Reason For Leaving *

Layoff

Discharge

Resign

Still Employed

Was this position subject to USCG regulation? *

Yes

No

Was this position regulated by Federal or State drug and alcohol testing requirements? *

Yes

No

Contact Person

First Name

Last Name

Company Phone #

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Reason for Leaving

Layoff

Discharge

Resign

Was this position subject to USCG regulation?

Yes

No

Was this position regulated by Federal or State drug and alcohol testing requirements?

Yes

No

Contact Person

First Name

Last Name

Company Phone #

(###)

###

####

Start Date

MM

DD

YYYY

End Date

MM

DD

YYYY

Reason for Leaving

Layoff

Discharge

Resign

Was this position subject to USCG regulation?

Yes

No

Was this position regulated by Federal or State drug and alcohol testing requirements?

Yes

No

Reference #1 *

First Name

Last Name

Phone # *

(###)

###

####

Business or Personal (not related)

Business

Personal

Reference #2

First Name

Last Name

Phone #

(###)

###

####

Business or Personal (not related)

Business

Personal

Reference #3

First Name

Last Name

Phone #

(###)

###

####

Business or Personal (not related)

Business

Personal

Do you have a legal right to work in the United States? *

Yes

No

Are you a US Citizen or a Permanent Resident of the United States? *

Yes

No

Did you serve in the US Armed Forces? *

If YES, please fill out questions below (Copy of DD214 is required) If No, please proceed to next section

Yes

No

Date of Entry

MM

DD

YYYY

Date of Discharge

MM

DD

YYYY

Overseas Service?

Yes

No

1. Have you ever been convicted or adjudicated of a crime? *

California applicants: Do not identify convictions under California Health & Safety Code §§11357(b) or (c), 11360(b) (formerly subdivision (c) of section 11360), 11364, 11365, or 11550 related to marijuana offenses that occurred two or more years before the instant application. Also, do not identify any conviction for which the record has been judicially ordered sealed, expunged or statutorily eradicated, or any misdemeanor conviction for which probation has been successfully completed or otherwise discharged and the case has been judicially dismissed.

Yes

No

2. Are you currently under any investigation or pending charge? *

Yes

No

3. Are you currently awaiting trial for any criminal offense? *

Yes

No

4. Have you ever initiated an act of violence in the workplace? *

Yes

No

5. Have you ever been sanctioned or had your driver's license suspended or revoked? *

Yes

No

APPLICANT'S STATEMENT AND ACKNOWLEDGMENT *

1. I certify that this application was completed by me and that all of the information furnished on this application and during the application process is true, complete and correct to the best of my knowledge. 2. I understand that any misrepresentation or omission of facts called for on this application or during the application process may result in termination of the application process or my dismissal from employment at any time regardless of when the false answer or omission is discovered. 3. I authorize the Company to conduct any necessary investigations or inquiries regarding my background to the extent permitted by federal, state and local law. I agree to complete the requisite authorization forms for the background investigation. I hereby release all parties from any liability in connection with the provision and use of such information. 4. I understand that if offered employment, I am to abide by all rules and regulations of the Company. 5. I recognize that this employment application is not an offer of employment. I agree that if I am hired by the Company, I will be an at-will employee, meaning that either the Company or I may end the employment relationship at any time with or without cause. 6. I understand and agree that, except for employment-at-will status, if hired my wages, hours, working conditions, job assignment(s), and compensation rate(s) will be subject to change by the Company. 7. I understand that the Company may share the information contained in this application with other Company employees for employment and administrative purposes and hereby consent to such transfer. 8. I consent to all of the following pre-employment processes, which are required by the Company and I further understand that the offer of employment is contingent upon my successfully completing all of pre-employment testing: a. Motor Vehicle Report (MVR) (review of past driving record) b. Drug screen (DOT and Non-DOT applicants) c. Previous Employer Drug and Alcohol History (49 U.S.C. §§ 40113, 44702, 44703, 44709, 49 CFR Part 40.25) d. Physical Examination and Functional Capacity Evaluation (consistent with federal and state law) e. Background Check 9. I agree and understand that this application for employment in no way obligates the Company to employ me.

Read and Acknowledged

Print Name *

First Name

Last Name

Date of Application *

MM

DD

YYYY

A. Do you currently posses a license as Captain? *

Captain

Pilot

Tankerman

Engineer

Mate

None of the Above

B. Have you ever been denied , suspended, and/or revoked a Merchant Mariner Credential (MMC)? *

Yes

No

Not Applicable

C. Have you tested positive, or refused to test, on any pre-employment, random, follow-up or periodic testing drug or alcohol test administered a maritime employer to which you applied for, but did not obtain, safety-sensitive transportation work Covered by DOT agency drug and alcohol testing rules during the past five (5) years as defined under 46 CFR 16.201? *

Yes

No

D. If you answered yes to C, can you provide/obtain proof that you've successfully completed the DOT Return-to-Duty requirements? *

Yes

No

Not Applicable

E. Do you currently posses a TWIC (Transportation Worker Identification Card)? *

A TWIC card is a requirement to work on a vessel, if you do not have one however it is applied for you may still apply for this position and follow-up when the card is in your possession.

Yes

No

Applied For

Date of Incident #1

MM

DD

YYYY

Fatalites/Injuries

Yes

No

At Fault?

Yes

No

Date of Incident #2

MM

DD

YYYY

Fatalities/Injuries

Yes

No

At Fault?

Yes

No

Today's Date *

MM

DD

YYYY