Personal Information

First   MI   Last

Address          

City    State       Zip

Are you 18 or Older?  Yes No

Telephone Number 

May we contact you at work? Yes   No

If yes, work number

Are you a U.S. citizen, or an alien legally authorized to work in the United States?

Yes   No

Education

High School       City 

Last year completed                 Did you graduate Yes  No

College        City 

Last year completed                 Did you graduate Yes  No

Trade        City 

Last year completed                  Did you graduate Yes  No

U.S. Merchant Marine Document

Tankerman's Ticket Information

Tankerman Document expires Month 1 2 3 4 5 6 7 8 9 10 11 12    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Issued by        Grade 

Fire Fighting Class taken          Month 1 2 3 4 5 6 7 8 9 10 11 12    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Location

Dangerous Liquid Class taken   Month 1 2 3 4 5 6 7 8 9 10 11 12    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015  

Location

Respirator Fit Test last on       Month 1 2 3 4 5 6 7 8 9 10 11 12    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Conducted by  

Last Benzene Training date     Month 1 2 3 4 5 6 7 8 9 10 11 12    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Conducted by  

Do you have a Benzene certification card       Yes  No

Restrictions / Limitations / Waivers

FCC Radio Telephone Permit issued             Month 1 2 3 4 5 6 7 8 9 10 11 12    Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Experience

 

Deckhand Experience (explain)

Tankerman Experience (have you handled)

Split Cargo      Yes  No 

Chemicals       Yes  No

Bunkering       Yes  No

Hot Oil           Yes  No

Close Gauging Yes  No

Vapor RecoveryYes  No

Other Experience

Geographical areas worked

 

U.S. Military Experience

 

Branch            Rank  

Reserves  

Type of Discharge  

Are you serving in the National Guard or Reserves?    Yes  No

Former Employment

A complete employment history since the age of 18 is required to present.

(From Present to Last)

(1)  From   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010         To   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Last Position              Salary  

Company, Phone, Supervisor

Reason for Leaving

(2)  From   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010         To   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Last Position              Salary  

Company, Phone, Supervisor

Reason for Leaving

(3)  From   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010         To   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Last Position              Salary  

Company, Phone, Supervisor

Reason for Leaving

(4)  From   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010         To   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Last Position              Salary  

Company, Phone, Supervisor

Reason for Leaving

(5)  From   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010         To   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Last Position              Salary  

Company, Phone, Supervisor

Reason for Leaving

(6)  From   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010         To   Month 1 2 3 4 5 6 7 8 9 10 11 12        Year 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1988 1987 1989 1990 1991 1992 1993 1994 1996 1997 1995 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Last Position              Salary  

Company, Phone, Supervisor

Reason for Leaving