EMPLOYMENT APPLICATION - Brusco Tug

1 EMPLOYMENT APPLICATION . Name Last First: Middle: Mailing/Street Address: City: State: Zip : Telephone Number: Email address: Position Applied For: Date of APPLICATION : How did you hear of this opening? Have you worked for Brusco previously? Yes No If yes, when/position? _____. Do you have relatives employed at Brusco ? Yes No If yes, who? _____. If yes, what is their relationship to you ( father, cousin, etc)? EMPLOYMENT History (List most recent employers first). Add additional pages if necessary to cover at least the last 10 years. Please explain any gaps in EMPLOYMENT history. Company Name: City: State: Zip: Dates of EMPLOYMENT From: To: Reason for Leaving: Position: Name of Supervisor: Phone: May we Contact Them? Yes No Company Name: City: State: Zip: Dates of EMPLOYMENT From: To: Reason for Leaving: Position: Name of Supervisor: Phone: May we Contact Them?

2 Yes No Company Name: City: State: Zip: Dates of EMPLOYMENT From: To: Reason for Leaving: Position: Name of Supervisor: Phone: May we Contact Them? Yes No Company Name: City: State: Zip: Dates of EMPLOYMENT From: To: Reason for Leaving: Position: Name of Supervisor: Phone: May we Contact Them? Yes No Brusco Tug & Barge, Inc. EMPLOYMENT APPLICATION v0713 pg 1 of 2. Education and Training Grade Year Degree School Level School Name & Location Completed Completed Acquired High School College Military Other Technical/Voc List of Mariners Documents and Licenses (Please check only those that apply to you and provide copies of documents, and training certifications). Mariner License Number Captains License (Tonnage) Mates License (Tonnage). Engineer (Type of License) MMD (Zcard Endorsements). GMDSS FCC Radio Radar First Aid/CPR Basic Fire Fighting Water Survival Vessel Security STCW 95 Safe Gulf Personal Safety Rigger TWIC Other _____.

3 Other Are you authorized to work in the United States? Yes No Are you at least 18 years old? Yes No For mariner position applicants, are you eligible for entry into Canadian waters? Yes No What else should we know about your qualifications for the job? References (Please list three professional references that we may contact). Name: Company/Position: Phone: Name: Company/Position: Phone: Name: Company/Position: Phone: I certify that the facts set forth in this APPLICATION for EMPLOYMENT are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this APPLICATION shall be considered sufficient cause for dismissal. This company is hereby authorized to make any investigation of my prior educational and EMPLOYMENT history, as well as follow up with references indicated above. I understand that EMPLOYMENT at this company is at will, which means that either I or the company can terminate the EMPLOYMENT relationship at any time, with or without prior notice, and for any lawful reason.

4 No person other than the President of Brusco Tug & Barge may modify or amend these provisions. In the event that I am eventually employed by Brusco Tug & Barge, Inc., I agree to abide by all policies, procedures, rules, and regulations set forth by law or by the company. If selected for a position following this APPLICATION and interview, prospective employees may be required to submit to a post offer, pre- EMPLOYMENT criminal background and driving record check, as well as a fit for duty physical and drug/alcohol test. I fully understand this requirement and agree to such testing. Name _____ Signature _____ Date _____. Brusco Tug & Barge, Inc. is an equal opportunity employer and is committed to making all EMPLOYMENT decisions without regard to race, color, religion, national origin, ancestry, sex/gender, pregnancy, age, veteran status, genetic information, marital status, disability, sexual orientation, or any other protected class.

5 Brusco Tug & Barge, Inc. EMPLOYMENT APPLICATION v0713 pg 2 of 2.