MILITARY2MARITIME THE GREAT LAKES TOWING COMPANY
YOU SERVED OUR COUNTRY. NOW LET US CONNECT YOU TO A PROMISING CAREER IN MARITIME AT THE GREAT LAKES TOWING COMPANY.
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A LETTER FROM OUR PRESIDENT..................................................................................4 ABOUT THE GREAT LAKES TOWING COMPANY........................................................5 TOWING & SHIP ASSIST............................................................................................6 CARGO TRANSPORTATION, BARGING & LOGISTICS.....................................7 ICE BREAKING.............................................................................................................8 EMERGENCY ASSISTANCE......................................................................................9 ABOUT GREAT LAKES SHIPYARD.................................................................................10 CAREERS AT GREAT LAKES.............................................................................................13 NOTES FROM THE GREAT LAKES..................................................................................19 MEET OUR FLEET CAPTAIN....................................................................................19 MEET OUR PORT CAPTAIN IN SAULT STE. MARIE.........................................20 MEET OUR PORT CAPTAIN IN DULUTH..............................................................21 HISTORY.................................................................................................................................22 CONTACT US........................................................................................................................25 APPLICATION.......................................................................................................................26
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T HE G R E AT L A KES TO WI N G CO MPA NY SIN CE
1 89 9
G R E AT L AKES S HI PYAR D The Great Lakes Towing Company 4500 Division Avenue Cleveland, OH 44102-2228 All of us at The Great Lakes Towing Company are inspired by the service and great sacrifice our military has made for our country. The strength of our veterans reflects the very best of the United States, which is why The Towing Company is thankful and humbled to participate in the Military2Maritime program, and appreciate the opportunity to recruit skilled individuals like yourself to join The Company. I hope that the following pages share our passion for the industry and the essential services we provide to the merchant vessels trading on the Great Lakes and St. Lawrence Seaway system. More importantly, I hope that you apply for a career position with The Towing Company — to become part of our team, its 116-year history, and to help us build a better future. Thank you for your service to our country.
Joseph P. Starck, Jr. President The Great Lakes Towing Company
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THE GREAT LAKES TOWING COMPANY
The Great Lakes Towing Company, popularly called “The Towing Company,” operates the largest and most experienced US-flag tugboat fleet. The Towing Company is a significant marine operations link in North America’s US Great Lakes-Saint Lawrence Seaway marine transportation network –the fourth seacoast of the United States, an operating area that extends over 8,300 miles of shoreline, encompassing a water surface area of roughly 100,000 square miles. Our services include: • Towing & Ship Assist • Cargo Transportation, Barging & Logistics • Ice Breaking • Emergency Assistance • Chartering 5
TOWING & SHIP ASSIST
The Great Lakes Towing Company has continuously evolved to meet the changing demands of the agricultural, steel, and construction industries along with the needs of the ships and tug/barge units which serve those industries by adapting and improving its services to the requirements of each new day. With the largest US-flag tugboat fleet of more than 35 tugboats strategically stationed in 11 ports stretching across the Great Lakes region, the Towing Company provides harbor assist and towing services to both domestic and foreign-flag vessels in more than 40 ports lakes-wide. Our record of timely performance and safety is unmatched in the industry.
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CARGO TRANSPORTATION, BARGING & LOGISTICS
The Towing Company offers barge transportation and logistics services on the Great Lakes with transshipment opportunities to the Mississippi River system, Canada, other seacoasts. Cargoes may range from components for power generation and distribution, such as boilers, turbines, generators, transformers, to large quantities of break bulk project cargoes. The Company coordinates the movements and facilitates shipper and receiver interests as well as the interest of underwriters including surveyors and regulatory agencies, like the US Coast Guard.
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ICE BREAKING
The Great Lakes Towing Company’s tugs are available to perform commercial ice breaking services during the winter months of the Great Lakes Navigating season. Our tugs are capable of breaking ice of up to three feet thick and windrows up to six feet high. Normally, we provide ice breaking services within the harbors and in dock areas and slips. The Towing Company provides commercial ice breaking in ports and harbors throughout the Great Lakes. The US and Canadian Coast Guards provide ice breaking assistance in waters where commercial icebreaking resources are either unavailable or incapable of handling the difficult ice conditions.
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EMERGENCY ASSISTANCE
Emergency assistance is provided to vessels that are wrecked, disabled, or in distress on the US and Canadian Great Lakes. When the safety of vessels and their crew are at risk, the Company can mobilize a network that encompasses the best equipment and the most prepared technical and operational employees. Centralized 24-hour control of its vast operating area is maintained through a state-of-the-art operations, communications, and tracking center, which allows the Company to provide you with the highest standards of service. Emergency assistance is also provided to vessels in Canadian waters under a Treaty between the United States and Canada. No claim for salvage under the maritime laws is made for emergency services provided under the Company’s Lakes-Wide Towing Contract.
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GREAT LAKES SHIPYARD
The Towing Company’s operations include a shipyard and drydock that do business under the name Great Lakes Shipyard (GLS). GLS facilities are located at the Company’s headquarters on the Old River Channel of the Cuyahoga River in Cleveland, Ohio and it specializes in all types of marine construction and repair services. Throughout its 116 year history the Company has always maintained a shipyard and drydocking facility in Cleveland. Initially 10
established for maintenance and repairs of its own fleet of tugs and barges, the shipyard was expanded in the early 1980s, to include commercial marine repair services for all types of commercial and government vessels. Then, in the mid-2000s, GLS entered the new vessel construction market. GLT’s shipyard expertise includes designing, building and maintaining its own fleet, as well as an extensive list of commercial and government
GREAT LAKES SHIPYARD
tugboats, supply boats, ferries, barges, cruise boats, large yachts, and many other types of vessels, including larger domestic and foreign cargo vessels. The shipyard is a major contractor for the US Coast Guard, US Geological Survey, the Army Corps of Engineers, the US Navy, NOAA, and many other federal, state and local governments, attesting to its high-quality workmanship, on-time performance,
and competitive pricing. The GLT tug fleet remains a major customer of the drydock and Great Lakes Shipyard. GLS provides topside work of every kind to lakers and saltwater vessels of various sizes, calling at the Port of Cleveland or on the Cuyahoga River, either at the shipyard or at the customer’s berth. The Shipyard’s competitive edge has always been its consistent, 11
GREAT LAKES SHIPYARD
prompt, high-quality service. The Shipyard’s performance record reflects that all jobs are completed on time and on budget. Since GLS services the Company’s own fleet of GLT tugboats, it understands what vessel owners expect and provides them with the same level of quality workmanship and service GLT expects for its own fleet.
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SERVICES • Custom Fabrication & Repairs • Winter Layup Work • 5-Year Regulatory Surveys & Inspections • Drydocking • Electronics & Navigation Systems • Blasting & Painting • Conversions, Repowers & Refits • Mobile Repairs • 24/7/365 Emergency Repairs • New Construction
CAREERS
The core of The Great Lakes Towing Company is its people afloat and ashore. Our people, working as a team, are trained and skilled in the business of marine transportation, shipbuilding, fabrication, and repair. The success of our Group depends on the ability and willingness of our people to provide our customers with the most courteous and professional services with particular attention to safety and the environment. Our goal is to attract and retain the best people available. Some of our employees’ families have worked for The Towing Company for even three or four generations.
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CAREERS
A career at The Towing Company offers great opportunities: • Competitive pay and benefits • A skilled profession that requires excellence and experience • Exciting alternative to a 9-to-5 job • A chance to learn a trade • Extended time off • Opportunities for advancement • Flexibility to live where you choose • Pride as part of an industry vital to America 14
Our commitment to our employees is reflected in our excellent compensation and benefits package that includes: • Healthcare, Dental and Vision • Short-term and long term Disability Insurance • Employee assistance program • 401(k) profit sharing plan • Vacation and sick time • Company paid holidays • A friendly working environment
CAREERS AFLOAT
The Towing Company has sea going jobs for veterans across the Great Lakes and St. Lawrence Seaway system, including opportunities as: • Captain • Engineer • Deckhand The Towing Company proudly supports maritime training and education programs. Our goal is to continuously improve the quality of customer service by investing
in our employees. We place the highest priority on safety to protect life, property, equipment, and the environment. This is evident in our thorough environmental, safety, and quality assurance programs, policies, and training. The Towing Company operates its fleet and its facilities having best practices that exceed governmental regulation, and those of the American Waterways Operators. 15
CAREERS ASHORE
Great Lakes Shipyard has jobs for veterans at our world-class facility in Cleveland, Ohio, including opportunities as: • Welder • Mechanic • Outside Machinist • Hull Technician • Project Engineer • Quality Assurance Manager
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AFFILIATIONS
MASTERS, MATES, AND PILOTS & SEAFARER’S INTERNATIONAL UNION The Great Lakes Towing Company is the largest employer of Tugmen on the Great Lakes. Our licensed Captains and licensed Engineers are affiliated with the International Organization of Masters, Mates & Pilots (MMP), Great Lakes and Rivers Maritime Region, AFL-CIO. Our Deckhands and Acting Engineers are affiliated with the Seafarers International Union (SIU) of North America, Atlantic, Gulf, Lakes, and Inland Waters District/NMU, AFL-CIO. Both of these maritime unions are the strongest supporters of the American Merchant Marine and our veterans from all Armed Services.
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OPPORTUNITY
EQUAL EMPLOYMENT OPPORTUNITY, AFFIRMATIVE ACTION, & M/F/D/V The Company is proud to be an Equal Employment Opportunity (EEO); Affirmative Action (AA); and minority, female, disability, and veteran-friendly employer (M/F/D/V). Our commitment to equality of opportunity supports the continued growth and vitality of our Company. We believe that the diversity of our workforce is advantageous to us and provides us with a broad spectrum of ideas which enhance our efficiency, production, products and services. By actively encouraging diversity and affirmative action, we believe that we also contribute to our community.
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NOTES FROM THE GREAT LAKES MEET OUR FLEET CAPTAIN
“IT’S GOOD SEAMANSHIP TO TAKE A TUG.” Jeff Stabler has lived by the standards of the master mariner for over 20 years — everywhere from the Arabian Sea, to the Red Sea, to the Caribbean Sea, the Atlantic Ocean and the Gulf of Mexico, and now on the Great Lakes. As Fleet Captain of The Great Lakes Towing Company, Stabler ensures that his tug crews provide the best and safest service. “We want our Captains and their crews to have the confidence they need to get through any situation. That’s why we are on time, and don’t delay our customers. And we do that time and time again, without cutting any corners. That’s how we operate 100% of the time.” The tugs operated by the Towing Company have the longest running history for safety and dependability,
while providing critical and essential services to Lakers and Salties in ports throughout the Great Lakes and St. Lawrence Seaway system. The Towing Company’s network of tugs are stationed in 11 ports, and serve more than 40 ports and harbors across all eight Great Lakes states. Ship assistance provides an added level of safety and security for the captain and owner of the vessel. Not only is it safe, it’s smart. Taking a tug decreases the chance of ships becoming involved in a marine causality, such as running aground or hitting a dock. It’s added insurance to take a tug. Don’t leave your port without one. According to Stabler: “The expertise of the vessel’s captain
is not the problem, they have the experience. It’s the capability or limitations of their vessel that can reduce their abilities. Even with a bow or stern thruster, they might not be able to operate safely and effectively in severe conditions or even shallow water without a tug. That’s where we can assist most, and add our years of experience together with the vessel captain’s to create a plan and help maneuver the vessel safely. But even in good conditions, it’s just good seamanship to take a tug. You never know what could happen. The smallest mistake or unanticipated circumstances could have devastating consequences. We help the captain decrease the chance of that happening.”
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NOTES FROM THE GREAT LAKES MEET OUR PORT CAPTAIN IN SAULT STE. MARIE
“YOUR REPUTATION IS ON THE LINE WITH EVERY TOW.” With over 40 years of experience, Captain Mike Patterson has honed skills that he now feels passionately about passing down to the next generation of tugmen at The Great Lakes Towing Company. “One of the things I’ve always liked best about the job is that a captain can’t do it alone. We work as a team. Every time we’re out there we have to remember that we are there for a reason – our customers depend on us to get them to the dock. We do it for them and for our own self-pride… your reputation is on the line with every tow.” His illustrious career includes countless successful tows into port and helping ships through treacherous ice conditions. “Ice breaking is a very delicate business,”
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says Patterson. “You have to loosen the ice without damaging the boats. You have to have stamina. You’re gone all day and into the night. There’s no rest. It’s really intense brutal on the tugs and on the men. You have to be a bit of an adrenaline junkie to do this kind of work.” Patterson loves his job, he takes great pride in having started from square one and learning from mentors like his own father. “Anyone getting into this industry should start at the bottom and work their way up. You learn the hard way, but it makes you better at your job. This will make you a better captain.” Safety comes with experience. The tugmen at The Great Lakes Towing Company, in Patterson’s estimation as well as many industry experts, “…
are more experienced than any of the competitors. The competition thinks what we do looks easy - it’s not. They can make costly mistakes, that our experience will prevent, which gives our customers an edge when they use a G-tug.” “If you’re the captain of a vessel and have an accident, the first thing you’re asked is if you did everything you could to prevent the accident that includes using our tug services. Taking a tug is an extra cost, but the cost is nothing when you consider the cost of an accident. The low cost of taking a tug far outweighs the cost of an accident. It’s cheap insurance.”
NOTES FROM THE GREAT LAKES MEET OUR FLEET PORT IN DULUTH
“THERE IS ABSOLUTELY NO SUBSTITUTE FOR EXPERIENCE.” As the employee with the most years of service at The Great Lakes Towing Company, Duluth-based Tug Captain, Dean Olson, understands how to achieve success on behalf of customers, even in the most challenging of conditions. “It’s about teamwork. Working in harsh winter conditions where there is extreme ice breaking needed is probably the most challenging thing about this job. It takes a lot of time and hard work to break through ice. It requires an experienced crew and a lot of hard work.” Last winter presented The Towing Company with extreme conditions on the Great Lakes. The work was intense, demanding and constant. But, according to Olson, also extremely fulfilling: “It’s rewarding to
help boats go where they need to go, to see how hard these tugs work and to be a part of it.” Olson began his maritime career in 1972. “I didn’t know the bow from the stern. But, I learned quickly everyone was willing to help you out, to teach you,” he says. Everyone, including his father who also worked for The Towing Company. “It was a good thing to work with my father. He had a lot of patience with me,” Dean chuckles.
a level of professionalism that is greater than that of competitors. We have many full-time crew members, which means consistency along with 24/7 support for customers.” The Towing Company has a longstanding relationship with the Port of Duluth as well as with its community. Its experience towing vessels in this area is unparalleled. And when winter comes on the Great Lakes, as Olson says, “There’s absolutely no substitute for experience.”
When asked if The Towing Company is ready for this winter’s conditions he states: “We are definitely prepared for another bad winter, should that happen.” As for what makes The Towing Company the best in class: “Throughout the Company’s longstanding history we have offered
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HISTORY
The Great Lakes Towing Company has played a major role in the maritime industry on the Great Lakes since its incorporation on July 7, 1899. The Company’s founding shareholders comprised a veritable “Who’s Who” of the nation’s great industrialists of the day, including John D. Rockefeller, Jeptha H. Wade, and James R. Sinclair, among others. Popularly called “The Towing Company” for its entire 116-year history, the Company has been a significant marine operations link in one of the major economic lifelines of North America -- the fourth seacoast and the Great Lakes Seaway System.
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HISTORY
The Towing Company has continuously evolved to meet the changing demands of the agricultural, steel, and construction industries, and the needs of the ships and tug/barge units which serve those industries. What is not so widely known is that “The Towing Company” is now a full-service marine transportation company – actually a “Group” of companies engaged in marine-related businesses operating on the East, Gulf, and West Coasts of the United States, as well as in Puerto Rico, in the islands of the Caribbean, and internationally.
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SUBMIT YOUR APPLICATION & RESUME TODAY Candidates must be able to pass a background check, chemical testing, and E-Verify authorization. If you meet the minimum essential requirements for the job and are looking for a company to make your home, complete our job application on the following pages and submit it with your resume to the human resources department: Wanda Reddy, Human Resources Manager Phone: 216-367-8139 Fax: 216-621-7616 Email: hr@thegreatlakesgroup.com To be part of our team means to be part of our family and the tradition of our company. We look forward to meeting you.
VISIT US
CONTACT US
4500 Division Avenue Cleveland, Ohio 44102-2228
Phone: 216-621-4854 Fax: 216-621-7616 Email: marketing@thegreatlakesgroup.com Website: www.thegreatlakesgroup.com
FOLLOW US facebook.com/GreatLakesGroup twitter.com/GreatLakesGroup linkedin.com/company/GreatLakesGroup instagram.com/GreatLakesGroup youtube.com/GreatLakesGroup
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For Puerto Rico: ATTN: Human Resources Pier 15 Calle Miraflores Esq. Villa Verde San Juan, PR 00907 (787) 722-1500
For Great Lakes: ATTN: Human Resources 4500 Division Avenue Cleveland, OH 44102-2228 (216) 621-4854
INSTRUCTIONS: This application (Parts I, II, III and IV as applicable) for a Conditional Job Offer, must be completed in its entirety, and submitted with resume and required documentation (as indicated) to be considered for employment. Incomplete applications will not be considered. The Application consists of:
Employment Application For a Conditional Job Offer Shipyard and Vessel Personnel (Directly affect safety or potentially dangerous)
• Part I (to be completed by all applicants); • Part II and Part III (to be completed by applicants for Vessel Positions Afloat and Ashore (e.g. tug crews, shipyard employees, and • Part IV (OPTIONAL), (to be completed by veterans only) The Company may ask disability-related questions; require medical examinations and require submission of further documentation and information from an applicant after the applicant has been given a Conditional Job Offer. Upon receipt and review of requested submissions, documentation, and information, to the satisfaction of the Company, the Company may make a Conditional Job Offer to the applicant, and require an interview, but the Company is under no obligation to do so. Applications are considered active for 45 days, at which point applicants not hired must reapply. Completeness and neatness of this application will be used in considering suitability of applicant for the position applied for. If information is not applicable, then write "N/A". DO NOT leave any blanks. DO NOT write in the shaded areas. “Equal Opportunity/Affirmative Action Employer”
We ensure that all individuals have an equal opportunity for employment, without regard to race, color, religion, sex, national origin, disability or status as a veteran. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Our company Affirmative Action Program refers to our aggressive recruitment programs, mentoring, training, and family programs that work to recruit and retain qualified individuals. Equal access to employment services and programs are available to all persons. Those applicants requiring reasonable accommodations to the application and/or interview process should notify the Company personnel representative at the address shown above.
Part I 1. Date of Application
2. Name
(Month) (Date) (Year)
(First)
(M.I.)
(Maiden-Optional)
(Last)
3. Social Security Number
4. Home Telephone Number (including area code)
5. E-Mail Address
6. Mobile or Other Telephone Number where you can be reached
7. Driver's License No.
10. Emergency Contact and Relationship to you
7(a) State of Issue
(Contact)
7(b) Expiration Date (Month, Day, Year)
(Relationship)
8. Are you a U.S. Citizen 9.
(including area code)
8(a) If “No”, Do you have a Current Work Visa
Yes
No
Yes
No
11. Emergency Contact’s Telephone Number (including area code)
12. Second Emergency Contact’s Telephone Number (including area
8(b) If Yes, Country of Issue
code)
8(c) Expiration Date (Month, Day, Year)
9. Do You Have a Passport? 9(a) If so, Expiration Date (Month, Day, Year)
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Yes
No
13. Emergency Contact’s E-Mail Address
14. Birth Place: (City)
(State)
(Country)
15. Present Mailing Address Street
Apartment Number
City
State
ZIP Code
16. Permanent Mailing Address (Indicate "same" if same as block 15.) Street
Apartment Number
City
State
ZIP Code
17. Date Available to Start Work Check here, if immediately available, or enter date:
18. Which Company are you applying to? (Check all that
Month
19. Location Preference (Check all that apply)
apply)
The Great Lakes Towing Company 速
Cleveland, OH (Hqtrs.)
Puerto Rico Towing & Barge Co.
Great Lakes Ports
SM
Soo Linehandling Services, Inc.
Sault Ste. Marie, MI
Other (Specify) ___________________
If specific port(s) are desired, specify: __________________ Other (Specify) __________________
Day
Year
20. Which position are you applying for? (Check all that apply) (a) Vessel Afloat
(b) Vessel Ashore
(c) Office Position
Captain Engineer Deckhand/Acting Engineer Deckhand Captain - Alternate Engineer - Alternate Other (Specify) ________________
Port Captain Port Engineer Shipyard Employee Yardman Other (Specify) _________________
Accounting General Admin Engineering Operations Sales & Marketing Secretarial Other (Specify) _______________
(d) Linehandling Linehandler
21. Education and Training 21(a) High School (Write the name and location of the last high school you attended or where you obtained your GED high school equivalency) Name of High School
City
State
Years Completed (Check) 1
21(b) Did you receive a diploma?
Yes
No
2
If NO, Did you receive a GED equivalency? Yes
21(c) Have you ever attended college or graduate school? YES
if yes continue to block 21(d) No
3
4
No
If NO, go to block 21(g)
21(d) College/University Name of College/University School
Month and Year Attended Month
Year
The Great Lakes Group Revised 5/2012
City
State
Number of Credit Hours Completed Semester
Quarter
Type of Degree (e.g. BA, MA)
ZIP Code
Month and Year of Degree Month
Year
Page 2
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21. Education and Training (continued) Number of Credit Hours 21(e) Chief Undergraduate Subjects (Show Major on the first line) Semester Quarter
Number of Credit Hours Semester Quarter
Chief Graduate Subjects (Show Major on the first line)
21(f) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School
City
Month and Year Attended Month
Year
Class Room Hours
State
ZIP Code
Training Completed (Check Box)
Subject(s)
Yes
No
21(g) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School
City
Month and Year Attended Month
Year
Class Room Hours
State
ZIP Code Training Completed (Check Box)
Subject(s)
Yes
No
21(h) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School
City
Month and Year Attended Month
Year
Class Room Hours
State
ZIP Code
Training Completed (Check Box)
Subject(s)
Yes
No
21(i) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School
City
Month and Year Attended Month
Year
Class Room Hours
State
ZIP Code
Training Completed (Check Box)
Subject(s)
Yes
No
21(j) If you have completed any other courses or training related to the kind of job(s) you are applying for (business, vocational, trade, Armed Forces) provide information below. Name of School
City
Month and Year Attended Month
Year
Class Room Hours
State
Subject(s)
ZIP Code
Training Completed (Check Box) Yes
The Great Lakes Group Revised 5/2012
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No
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22. Employment History
Please start with your most recent job, and list your last four (4) employers or your employers during the past five (5) years. All past five (5) years of employment must be included. Attach additional sheets as necessary. Include military service assignments and volunteer activities. This information must be detailed below. If a resume is attached or has been previously submitted, ONLY include information that IS NOT on the resume. (Make sure you list Employer name with this information) 22(a) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? No A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior Yes to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR40.25 22(b) Name of Present or Last Employer
22(c) Address Street
Suite Number
City
State
ZIP Code
22(d) Present or Last Job Title
22(e) Dates of Present or Last Employment Month
Year
22(f) Name of Present or Last Supervisor (First)
Month
To
Year
22(g) Telephone Number
(Last)
Area Code
Prefix
Last 4 Numbers
22(h) Salary History (Present or Last salary held. Must be indicated in order for consideration) Wage (Per Hour, Day, Month, or Year as checked)
$
Per (Check One): Hour
Day
Month
Year
22(i) Duties Performed
22(j) Reason for Leaving
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22. Employment History (continued) 22(k) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? Yes No A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR40.25 22(l) Name of prior Employer
22(m) Address Street
Suite Number
City
State
ZIP Code
22(n) Prior Job Title
22(o) Dates of Prior Employment Month
Year
22(p) Name of Prior Supervisor (First)
Month
To
Year
22(q) Telephone Number (Last)
Area Code
Prefix
Last 4 Numbers
22(r) Salary History (Last salary held) Wage (Per Hour, Day, Month, or Year as checked)
$
Per (Check One): Hour
Day
Month
Year
22(s) Duties Performed
22(t) Reason for Leaving
The Great Lakes Group Revised 5/2012
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22. Employment History (continued) 22(u) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? Yes No A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR40.25 22(v) Name of prior Employer
22(w) Address Street
Suite Number
City
State
ZIP Code
22(x) Prior Job Title
22(y) Dates of Prior Employment Month
Year
22(z) Name of Prior Supervisor (First)
Month
To
Year
23(aa) Telephone Number (Last)
Area Code
Prefix
Last 4 Numbers
22(bb) Salary History (Last salary held) Wage (Per Hour, Day, Month, or Year as checked)
$
Per (Check One): Hour
Day
Month
Year
22(cc) Duties Performed
22(dd) Reason for Leaving
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22. Employment History (continued) 22(ee) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment? Yes No A "NO" will not affect the initial evaluation of your qualifications. If it is necessary to contact your present or last employer prior to final selection, you will be notified first. NOTE: If you are applying for a DOT-Regulated position, the Company is required to obtain Drug & Alcohol Testing information prior to employing someone in a safety-sensitive function in accordance with 49CFR40.25 22(ff) Name of prior Employer
22(gg) Address Street
Suite Number
City
State
ZIP Code
22(hh) Prior Job Title
22(ii) Dates of Prior Employment Month
Year
22(jj) Name of Prior Supervisor (First)
Month
To
Year
22(kk) Telephone Number (Last)
Area Code
Prefix
Last 4 Numbers
22(ll) Salary History (Last salary held) Wage (Per Hour, Day, Month, or Year as checked)
$
Per (Check One): Hour
Day
Month
Year
22(mm) Duties Performed
22(nn) Reason for Leaving
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Page 7
23. Professional References (List three [3] persons not listed in blocks 22(f), 22(p), 22(z), or 22(jj) who are not related to you, and who are familiar with you) 23(a) Name
23(b) Telephone Number
(First) May we contact? Yes
(Last)
Area Code
Prefix
Last 4 Numbers
No
23(c) Address
Street
Suite Number
City
State
ZIP Code
23(d) Nature of association with you
23(e) Name
23(f) Telephone Number
(First) May we contact? Yes
(Last)
Area Code
Prefix
Last 4 Numbers
No
23(g) Address Street
Suite Number
City
State
ZIP Code
23(h) Nature of association with you
23(i) Name
23(j) Telephone Number
(First)
May we contact? Yes
(Last)
Area Code
Prefix
Last 4 Numbers
No
23(k) Address Street
City
Suite Number
State
ZIP Code
23(l) Nature of association with you
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24. Professional, Educational or Civic Organizations (List memberships as indicated. You may exclude those which may disclose your race, color, religion or national origin) City
24(a) Name of Organization
State
May we contact? Yes No
24(b) Type of Organization
24(c) Nature of Membership
24(d) Dates of Membership: Month & Year
Month & Year TO City
24(e) Name of Organization
State
May we contact? Yes No
24(f) Type of Organization
24(g) Nature of Membership
24(h) Dates of Membership: Month & Year
Month & Year TO City
24(i) Name of Organization
State
May we contact? Yes No
24(j) Type of Organization
24(k) Nature of Membership
24(l) Dates of Membership: Month & Year
Month & Year TO
25. Active Military Service 25(a) Have you served in the United States Military Service? (If your only active duty was training in the Reserves or National Guard, answer "NO". Yes No If "YES" See attached Supplemental Part IV (Optional) - Special Notice to Covered Veterans 25(b) Did you retire? Yes
No
25(c) Were you discharged from the military service under honorable conditions? (if your discharge was changed to "honorable" or "general" by a Discharge Review Board, answer "YES". If you receive a clemency discharge, answer "NO".) If "NO", provide the date and type of discharge you received below: Yes No Month
Day
Year
Type of Discharge
25(d) If last employment was military service, attach copies of DOD Form DD-214 and, at the applicants option, attach your last three (3) performance evaluations prior to discharge. The Great Lakes Group Revised 5/2012
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26. Referral Information 26(a) How did you hear about the Company? (Check all that apply) Newspaper ad
Friend
Employee
Union
Website
Other (Specify)____________________________________
26(b) Were you referred by someone? (Check Box) Yes
No Name
If yes, by whom?
(Last)
(First)
26(c) May we contact them for reference? Yes
No
26(d) Have you ever applied to, or worked for a Company in the Great Lakes Group of Companies before?
Yes
Name of Company
If yes, name of Company and when?
Month
No Date Day
Year
27. Additional Questions NOTE: It is important that you give complete and truthful answers to questions below. If you answer "YES" to any of them, provide your explanation(s) in block 27(g). Include convictions resulting from a plea of nolo contenders (no contest). Omit: (1) traffic fines of $100.00 or less; (2) any violation of law committed before your 16th birthday; (3) any violation of law committed before your 18th birthday, if finally decided in juvenile court or under a Youth Offender law; (4) any violation of law aside under the Federal Youth Corrections Act or similar state law; (5) any conviction whose record was expunged under Federal or state law. We will consider the date, facts, and circumstances of each event you list. In most cases you can still be considered for employment. However, if you fail to tell the truth or fail to list all relevant events or circumstances, this may be grounds for not hiring you, or for firing you after you begin work 27(a) During the last five (5) years, were you fired from any job for any reason, did you quit after being told you would be fired, or did you leave by mutual agreement because of specific problems? Yes No 27(b) Have you ever been convicted of, or forfeited collateral for any felony violation? (Generally, a felony is defined as any violation of law punishable by imprisonment of longer than one (1) year, except for violations called misdemeanors under State law which are punishable by No imprisonment of two (2) years or less). Yes 27(c) Have you ever been convicted, or forfeited collateral for any firearms or explosives violation? Yes 27(d) Are you now under charges for any violation of law? Yes
No
No
27(e) During the last five (5) years have you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not include violations reported in 27(b), 27(c), or 27(d), above. Yes No 27(f) Have you ever been convicted by a military court martial? If no military service, answer "NO". Yes
No
27(g) If "YES" in block 27(a): Explain for each job the problem(s) and your reason(s) for leaving. Give the employer's name and address. If "YES" in blocks 27(b) through 27(f): Explain each violation. Give place of occurrence and name/address of police or court involved. Item No.
Month & Year
Explanation
Mailing Address (Name of employer, Police, Court or Agency)
Item No.
Month & Year
Explanation
Mailing Address (Name of employer, Police, Court or Agency)
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35
Item No.
Month & Year
Explanation
Mailing Address (Name of employer, Police, Court or Agency)
Item No.
Month & Year
Explanation
Mailing Address (Name of employer, Police, Court or Agency)
Item No.
Month & Year
Explanation
Mailing Address (Name of employer, Police, Court or Agency)
Item No.
Month & Year
Explanation
Mailing Address (Name of employer, Police, Court or Agency)
28. Representations 28(a) Attendance: The Company is a service provider and employee attendance is critical to meet customer service demands. (i)
Are you able to meet the Company's attendance requirements? Yes
No
(ii)
How many days, other than vacation days, were you absent from your last job? Less than 5
6-10
More than 10
(iii) How many Mondays or Fridays were you absent last year on leave other than approved vacation leave? Number of Mondays _______________ Number of Fridays ___________________ (iv) Do you have any objection to working overtime if necessary? Yes
No
28(b) Illegal Drug Use / Medical History: (i)
Have you ever used illegal drugs? Yes
No
(ii)
Have you used illegal drugs within the last six (6) months? Yes
(ii)
Have you ever been convicted for driving under the influence of illegal drugs or alcohol? Yes
No
If yes, when was the last time you used illegal drugs? No
28(c) General Employment Information (i)
Can you travel if required by this position? Yes
(ii)
Can you submit proof of legal employment authorization and identity as required by governmental authorities?
Yes
No
Can you perform any or all job functions for the position applied for, with or without reasonable accommodation? Yes
No
(iii) Are you under eighteen (18) years of age? (iv)
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No
Yes
No
Page 11
29. Certifications 29(a) I understand that the Company's Policy on Alcohol, Drugs and Controlled Substances requires Chemical Testing for employees as listed below. I am willing to participate in the required PreEmployment Chemical Test and, if hired, to comply with the aforementioned Company policy.
(a)______ Initial
I. Vessel Employees Afloat: Pre-Employment, Periodic, Random, Reasonable Cause, Post-Accident Testing.
a. Any person, tugman, or crew member engaged or employed on board a Company tug, barge,
vessel, or equipment acting under the authority of a license, certificate of registry, or merchant mariner's document, whether or not a member of the Company tug's crew;
b. Any person employed shore side as an employee or supervisor, who, by virtue of his or her shore side position, may be engaged or employed on board a Company tug acting under authority of a license, certificate of registry, or merchant mariner's document, whether or not the employee is a member of the Company tug's crew.
II. Vessel Employees Ashore, Shipyard Employees and Linehandlers: Pre-Employment, Periodic, Random, Reasonable Cause, Post-Accident Testing.
a.
Any person engaged in duties which directly affect the safety of a Company tug's navigation or operations, or whose duties involve potentially dangerous and hazardous work that may endanger the safety of either themselves or other employees.
b. All Company shipyard, or other Company maintenance facility employees (excluding administrative and clerical personnel);
c. All other employees who perform repair and maintenance, construction, and reconstruction duties on board vessels and the dry dock;
d. All Soo Linehandling Services, Inc. employees (excluding administrative and clerical personnel); and Employees, in various ports
III.Administrative (including Management and Clerical) Personnel: Reasonable Cause Testing. a.
All shore side employees performing administrative, management, and clerical duties who are not engaged or employed on board a Company tug, barge, or vessel.
b.
Any person engaged in duties which DO NOT directly affect the safety of a Company tug's navigation or operations, or whose duties DO NOT involve potentially dangerous work that may endanger the safety of either themselves or other employees.
29(b) I certify that the information provided in this employment application for a Conditional Job Offer (and accompanying resume, or documentation, if any) is true and complete, and I understand that any false or misleading information, misrepresentation or material omission may disqualify me from further consideration for employment or immediate termination of employment, if I am employed, whenever it may be discovered. I agree to immediately notify the Company if I should be convicted of a felony, of any crime involving dishonesty, breach of trust, controlled substances, sexual misconduct, abuse, or violence, while my job application is pending, or during my period of employment if hired. The Great Lakes Group Revised 5/2012
(b)______ Initial
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37
29. Certifications 29(c) I understand that I am authorizing the release of pre-employment information gained through my employment references. This is to allow the Company to verify and, in the Company's discretion, to perform other background investigations to determine my qualification for employment. Further, I understand that the Company, through a separate Company may investigate my academic credentials, prior employment, personal/professional references, credit record, motor vehicle record, and/or criminal record. I understand that a report may include information obtained through personal interview regarding your character, general reputation, personal characteristics, and/or mode of living. I understand that I may make a written request to obtain a description of the nature and scope of any report, which is prepared regarding me.
(c)______ Initial
29(d) I understand that this Application is for a Conditional Job Offer and does not constitute an offer or create a contract of employment. I understand that if an offer of employment is made, and if hired, I am obliged to comply with the Company' current and subsequently adopted policies, including the Company's Employment Manual, the Company's Policy on Alcohol, Drugs and Controlled Substances, and the Company's Responsible Carrier Program Manual. I am also aware that the aforementioned Company Policies on Alcohol, Drugs, and Controlled Substances, among other things, prohibits the use and possession of intoxicants (dangerous drugs and alcohol) on Company property and vessels, and that violation of the Policies will result in disciplinary action, including suspension, and may result in termination of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time, for any reason, with or without notice. Accordingly, either the Company or I can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal law or state law. I understand that no person is authorized to change any of the items mentioned in this employment application for a Conditional Job Offer.
(d)______ Initial
29(e) I understand that if employed in a temporary position, I will not be entitled to health and other benefits afforded employees in permanent positions.
(e)______ Initial
29(f) I understand that it is the Company's policy not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the Americans with Disabilities Act.
(f)______ Initial
29(g) I understand that once I am offered a conditional job offer and I accept, I will be required to provide satisfactory proof of identity and legal work authorization before my initial start date. Failure to submit such proof and/or the Company not being able to confirm legal work authorization through the EVerify process, my conditional job offer with the company will be provoked.
(g)______ Initial
29(h) I understand that once I am offered a conditional job offer and I accept, a criminal background check will be performed. If I have not been totally honest with the Company on my background, my conditional job offer with the company will be provoked.
(h)______ Initial
I represent and warrant that I have read and fully understand the foregoing and that I seek employment under these conditions. Applicant’s Signature __________________________________________________________________ ADMINISTRATIVE (Including Management and Clerical) STOP HERE UNLESS A VETERAN: If a Veteran - Complete Part IV (Optional)
The Great Lakes Group Revised 5/2012
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Page 13
Part II
Supplemental Employment Application To be completed by Applicants seeking Vessel Positions Afloat and Ashore (including Shipyard) Only (If you are applying for an Office or Linehandling Position listed, DO NOT complete this Part II, unless also applying for a Vessel Position Afloat and/or Ashore) 30. U.S. Coast Guard Licenses and Document Information 30(a) Do you possess a U.S. Coast Guard Merchant Mariner No Document? Yes (If Yes, Complete blocks 30(b), 30(c), and 30(d) below)
30(f) Do you possess a U.S. Coast Guard License as a Captain, Mate, or Engineer? Yes No (If Yes, Complete blocks 30(f), 30(g), and 30(h) below)
30(b) Ratings held and expiration date: (If temporary, so state)
30(f) Licenses held and expiration date:
(Ratings)
Month
Day
30(c) Do you have a life boat endorsement? Yes
Year
(Licenses)
Month
Day
Year
No
30(d) List all limitations and endorsements listed on the back of your U.S. Coast Guard Merchant Mariners Document below:
30(g) List all limitations and endorsements listed on your U.S. Coast Guard licenses below:
(Limitations and endorsements)
(Limitations and endorsements)
30(h) For licensed Captain/Deck officers: Are you a qualified RADAR observer? Yes
No
31. Tug Experience 31(a) Do you have experience with the following type tugs? a.
Conventional Single Screw Tugs
Yes
No
b.
Conventional Twin Screw Tugs
Yes
No
c.
Tractor Tugs
Yes
No
d.
Reverse Tractor Tugs
Yes
No
e.
Z-Drives
Yes
No
f.
Cycloidal Propulsion
Yes
No
31(b) Do you have experience with the following type of tug work? a.
Harbor Docking/Ship assistance
Yes
No
b.
Escorting
Yes
No
c.
Tug Barge Units
Yes
No
d. Other (Specify) ______________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
g. Other (Specify) ______________________________________ ____________________________________________________________
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39
32. For applicants seeking Vessel positions Ashore (e.g. Port Captain, Port Engineer, Shipyard Employee, Yardman), indicate the level of experience you have had with the tools listed in block 34(a) and in performing the duties listed in block 34(b) using the scale below:
SCALE 0 - Indicates that you have not had any training or work experience 1 - Indicates that you have trained, but never had work experience
2 - Indicates that you have used/performed alone with little
supervision 3 - Indicates that you have used/performed and trained or supervised others
32(a) Use the Scale above to indicate your level of experience with the following tools or equipment: _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Pliers Hammer Screwdriver File Chisel Wrench Power Saw Portable Drill Power Shaper Mortiser Router Metal Shears Lathe Jointer Scrapper Power Sprayer Fork Lift
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Hand Truck Dolly Power Winch Grease Gun Impact Wrench Soldering Iron Wire Strippers Basic Voltmeter/Ohmmeter Hydraulic Bender Fire Extinguisher Other (Please Specify) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
32(b) Use the Scale above to indicate your level of experience in performing the following duties: _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Installed electrical cable Spliced cable Repaired telephone equipment Repaired electrical equipment & systems on ships Maintained electrical equipment & systems on ships Repaired electric motors Worked in a steam plant Worked in a diesel plant Worked as a machinist or welder Welded to fine tolerances Welded using processes such as brazing, beading, pressure welding, tack welding Worked as a pipefitter Repaired air conditioning equipment Repaired refrigeration equipment Painted metal surfaces (aircraft, ships, automobiles, etc.) Prepared metal surfaces for painting Painted surfaces other than metal (plastic, wood, etc.) Mixed paints, varnishes, stains Climbed ladders Handled heavy loads Worked in high places
The Great Lakes Group Revised 5/2012
40
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Worked with formal supply systems Performed inventory duties Maintained storerooms/stockrooms Maintained stock records Maintained budget records Planned for & ordered stock/parts Planned storage schemes Arranged items stored to allow for maximum use of space & proper issue Stored supplies Worked as an administrative assistant Worked in a payroll office Used instruction manuals Operated computer terminals Operated office machines Other (Please Specify) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
Page 15
PART II (CONTINUED) 33. For applicants seeking Vessel positions Afloat and Ashore (e.g. Captain, Engineer, Deckhand, Port Captain, Port Engineer, Shipyard Employee, Yardman), indicate the level of experience you have had with the tools listed in block 33(a) and in performing the duties listed in block 33(b) using the scale page 15: 33(a) Use the Scale on page 15 to indicate your level of experience with the following tools or equipment: _____ Diesel Engines (Main Propulsion) _____ Diesel Engines (Generators and/or small gasoline engines [small boat]) _____ Chipping Hammer (pneumatic) _____ Deck Winches _____ Bow Thruster _____ Pumps _____ Booms _____ Boilers (Main) _____ After Steering Engine _____ Davits _____ Ventilation Systems (HVAC) _____ Fathometer _____ Steering System (Bridge) _____ Main Electrical Switchboard _____ Anchor Windlass
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Capstans Automated Bridge Control AC Generators DC Generators Boiler water supply equipment Compressors Collision Avoidance Radar Gyro Compass (Master) Life boats Fire Detector System CO 2 Extinguishing System Inert Gas System Global Positioning System (GPS) Others (Please Specify) _____________________________________________________
33(b) Use the Scale on page 15 to indicate your level of experience in performing the following duties: _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Operated hydraulic equipment Repaired valves Tied knots Used life-saving equipment Chipped paint Spliced wire rope Spliced other rope (fiber) Operated davits Worked on slippery surfaces Handled lines Maintained engine machinery Took tank soundings Operated valves Lubricated engine equipment Used various lubricants Disassembled engine room equipment Assembled engine room equipment Read electrical meters Read mechanical gauges Cleaned burners Fired oil burners Assembled & disassembled burners Changed & cleaned strainers Operated & maintained burners Transferred fuel between tanks Pumped bilges Steered by Gyro Compass Steered by magnetic compass] Kept vessel on course Used navigational aids Used navigational rules & regulations Operated gas engines Operated diesel engines Packed shafts and bearings Repaired small boat hulls Performed preventive maintenance on engines Gas free engineer certified
The Great Lakes Group Revised 5/2012
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____
Installed hardware & fittings on launches Towed floating equipment with a launch Lubricated deck machinery Operated booms Rigged booms Stood anchor watch Stood gangway watch Stood bridge watch (underway) Stood engineroom watch (in port) Launched life boats Commanded life boars (oars) Tested boiler water Operated lube oil purifier Operated evaporators Operated main throttle Operated remote shut down devices for machinery spaces Operated machine lathe Fabricated parts Service storage batteries Kept deck log Kept engineering log Knowledge of ship trim and stability Cargo storage Slushed standing rigging Lubricated running rigging Serviced damage control lockers and equipment Used all types of firefighting equipment Taken on fuel, lube oil, and water Knowledge of computers Vessel application Operated computerized cargo systems Other (Please Specify) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________
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41
Part II (Last Page) Indicate training completed in the following areas by checking the appropriate box. In block 34(a) list other maritime training received such as courses in GYRO-COMPASS and RADAR. In block 34(b), list licenses and certificates you hold other than those issued by the U.S. Coast Guard. Certified Swimmer Yes No Lifeboatman Yes No HASWOPR (Date__________) Yes No CPR/First Aid Yes No Radio Operator (FCC) Yes No Other (Specify)______________ Yes No RADAR Operation Yes No Radio Operator (CB) Yes No __________________________ Yes No Yes No Diver (Shallow Water) GYRO-COMPASS __________________________ Yes No Yes No Diver (Deep Water GPS 34(a) List of other maritime training received: ________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 34(b) List of licenses and certificates you hold other than those issued by the U.S. Coast Guard: _______________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 35. On what type of vessels have you served? Tug/Vessel Name Tug/Vessel Type
Company
Position(s) Held
36. In what geographical areas have you worked? Please list the areas in which you have worked on board the above vessels, including any particularly noteworthy areas (i.e. river systems, difficult docking areas, etc.) Tug/Vessel Name Tug/Vessel Type Company Geographical Area
37. Have you ever been involved in any USCG-reportable accident? Yes 37(a) Date of Accident Month Day
, If yes, explain in blocks 37(a) and 37(b), No
Type of Accident
Accident Details
Type of Accident
Accident Details
Year
(Accident details continued)
37(b) Date of Accident Month Day
Year
(Accident details continued)
38. Photocopies (front &back) of documents required to be submitted with application for a Conditional Job Offer, Vessel Afloat & Ashore. 38(a) U.S. Coast Guard Merchant Mariners Document with endorsements as OS, AB, TANKERMAN, etc. 38(b) U.S. Coast Guard Captain, Mate and/or Engineer's License (if held) 38(c) FCC Marine Radio Operator Permit (f held) 38(d) RADAR Observer Certificate (if held and not included as an endorsement on U.S. Coast Guard License) Applicant's Signature for Vessel Afloat, Vessel Ashore, and Shipyard positions
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42
Date of Signature: Month, Date & Year
Page 17
Part III CONFIDENTIAL DRUG & ALCOHOL TESTING CONSENT TO RELEASE INFORMATION DOT REGULATION 49 CFR Part 40.25 39. Name (First)
(Middle)
(Maiden-Optional)
(Last)
40. Address Street
Apartment Number
City
State
ZIP Code
42. Home Telephone Number (Including area code)
41. Social Security Number
I hereby authorize my previous employer(s) that are covered by Department of Transportation Drug Testing Regulations (listed below – list all employers for the previous 24 months) to release the following information with regard to my chemical testing records to any one of, or to each of, The Great Lakes Group of Companies: 44. Date of Signature (Month, Day & Year)
43. Applicant's Signature
45. Name of prior DOT Employer
45(b) Telephone Number (including area code)
45(a) Name of Contact Person (First and Last name)
45(c) Dates of Prior Employment: Month & Year
Month & Year TO
45(d) Name of prior DOT Employer
45(f) Telephone Number (including area code)
45(e) Name of Contact Person (First & Last Name)
45(g) Dates of Prior Employment: Month & Year
Month & Year TO
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43
Part III (Last Page) 45(h) Name of prior DOT Employer
45(i) Name of Contact Person (First & Last)
45(j) Telephone Number (Including area code)
45(k) Dates of Prior Employment: (Month & Year)
(Month & Year) TO
45(l) Name of prior DOT Employer
45(m) Name of Contact Person (First & Last)
45(n) Telephone Number (Including area code)
45(o) Dates of Prior Employment: (Month & Year)
(Month & Year) TO
45(p) Name of prior DOT Employer
45(q) Name of Contact Person (First & Last)
45(r) Telephone Number (Including area code)
45(s) Dates of Prior Employment: (Month & Year)
(Month & Year) TO
45(t) Name of prior DOT Employer
45(u) Name of Contact Person (First & Last)
45(v) Telephone Number (Including area code)
45(w) Dates of Prior Employment: (Month & Year)
(Month & Year) TO
45(x) Name of prior DOT Employer
45(y) Name of Contact Person (First & Last)
45(z) Telephone Number (Including area code)
45(aa) Dates of Prior Employment: (Month & Year)
(Month & Year) TO
The Great Lakes Group Revised 5/2012
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Page 19
Part IV
Supplemental Employment Application - (OPTIONAL)
SPECIAL NOTICE TO “COVERED VETERANS”
Disabled, Other Protected, Armed Forces Special Medal, and Recently Separated Veterans Government contractors are subject to 38 U.S.C. 4212 of the Covered Veterans – “Veterans’ Employment Emphasis under Federal Contracts”. Revised law went into effect as of January 7, 2011. This revised law requires that government contractors take affirmative action to employ and advance qualified Covered Veterans in employment. The term “Covered Veteran” means any of the following veterans:
1. Disabled Veteran: Any veteran that served on active duty in the U.S. military ground, naval, or air services and is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs, or was discharged or released from active duty because of a service-connected disability.
2. Other Protected Veteran: Any veteran who served on active duty in the U.S. military ground, naval, or air
service during a war or in a campaign or expedition for which a campaign badge was authorized. 3. Armed Forces Special Medal Veteran: Any veteran who, while serving on active duty in the U.S. military ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 Fed. Reg. 1209). 4. Recently Separated Veteran: Any veteran who served on active duty in the U.S. military, ground, naval or air service during the three-year period beginning on the date of such veteran’s discharge or release from active duty. USERRA (The Uniformed Services Employment and Reemployment Rights Act) requires employers to go further than the ADA by making reasonable efforts to assist a veteran who is returning to employment in becoming qualified for a job. The employer must help the veteran become qualified to perform the duties of the position whether or not the veteran has a service-connected disability requiring reasonable accommodation. This could include providing training or retraining for the position. Additionally, reasonable accommodations may be available under USERRA for individuals whose service-connected disabilities may not necessarily meet the ADA’s definition of “disability.” USERRA also applies to all employers, regardless of size. Information on the reemployment rights of uniformed service personnel can be found on DOL’s website at www.dol.gov/vets. If you are a disabled veteran, or have a physical or mental handicap you may volunteer this information which will be treated as confidential. Additionally, not providing this information will not jeopardize or adversely affect your consideration for employment. If you wish to be identified, please check the appropriate box(es) and sign below. Submission is voluntary Disabled Veterans
Other Protected Veterans
Armed Forces Special Medal Veterans
Recently Separated Veterans
THE AMERICANS WITH DISABILITIES ACT (ADA) AMENDMENTS ACT OF 2008 Title I of the Americans with Disabilities Act (ADA) prohibits private and state and local government employers with 15 or more employees from discriminating against individuals on the basis of disability. Title I of the ADA also generally requires covered employers to make reasonable accommodations – changes in the workplace or in the way things are usually done that provide individuals with disabilities equal employment opportunities. The ADA makes it unlawful to discriminate in employment against a qualified individual with a disability, therefore, providing this information will not jeopardize or adversely affect your consideration for employment. Additionally, not providing this information will not jeopardize or adversely affect your consideration for employment. If you wish to be identified as an individual with a disability, please check: Yes, I am an individual with a disability. Signature
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Date of Signature (Month, Day & Year)
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T HE G R E AT L A KES TO WI N G CO MPA NY SIN CE
1 89 9
G R E AT L AKES S HI PYAR D