Superior Bay Marine of Alabama - Online Hiring Application

Step 1 of 6

Applicant Information

Complete every applicable field. Fields marked * are required.

Personal Data

Last name * First name * Middle name

Street or mailing address * City * State * ZIP code * Telephone * Email *

Date available to start Salary/day rate desired Position applied for *

Other position

Position Information

High school diploma or GED?

Yes No

Are you a citizen of the United States?

Yes No

Are you authorized to work in the United States on an unrestricted basis?

Yes No

Have you ever been convicted of a felony?

Yes No

If yes, explain

Have you been told the essential functions of the job or reviewed the job description?

Yes No

Can you perform the essential functions with or without reasonable accommodation?

Yes No

Education and Training

Special skills, maritime credentials, leadership experience, organizations or teams

Professional References

List three professional references not related to you. Personal unrelated references may be used when professional references are unavailable.

Step 2 of 6

Work and Military History

Start with your present or most recent employer and work backward. Include paid and unpaid positions.

Work History

Military Service

Branch of serviceService fromService to Rank at dischargeType of discharge

If other than honorable, explain

Applicant Certification

I certify that the facts in this application are true and complete to the best of my knowledge. I understand that false statements, omissions or misrepresentations may result in dismissal. I authorize Superior Bay Marine of Alabama, LLC to investigate the facts provided and contact listed references. I understand that employment is at will.

I have read and agree to the certification above. *

Applicant typed signature *Date *

Step 3 of 6

Employment Agreements and Consents

Read each section carefully before signing.

Employment Agreement

Agreement dateRoleBasic wage per dayPay frequency

This agreement contains the entire agreement between the parties and supersedes prior oral or written understandings concerning employment. Changes must be in writing and signed by both parties.

Employee typed signatureEmployee printed namePersonnel manager signature

Rules of Conduct

Initial each item to confirm that it has been read and understood.

Employee typed signatureDate

Drug and/or Alcohol Testing Consent

Read full consent statement

I agree, upon a request made under the drug/alcohol testing policy of Superior Bay Marine of Alabama, LLC, to submit to an authorized drug or alcohol test and furnish a urine, breath and/or blood specimen for analysis. I understand refusal or failure to cooperate may result in termination.

I authorize the Company, its physician and testing laboratory to collect, analyze and release test-related documentation to authorized Company representatives and governmental decision-makers when permitted or required. I understand that authorized persons will protect confidentiality to the greatest extent possible.

I understand that the Company may require a drug screen and/or alcohol test following an on-the-job accident or injury when circumstances suggest possible drug or alcohol involvement, and I agree to submit to such testing.

I have read and consent to the drug and alcohol testing statement.

Employee typed signatureDateEmployee printed nameCompany representative

Previous Employer Release - 49 CFR Part 40

Employee nameSS/ID number

I authorize release of information from my DOT-regulated drug and alcohol testing records by the previous employer listed below to Superior Bay Marine of Alabama, LLC in accordance with 49 CFR Part 40, section 40.25.

Employee typed signatureDate

Previous Employer

Employer nameDesignated representativeAddressPhoneFax

Consent to Search

I understand and acknowledge that Superior Bay Marine of Alabama, LLC may inspect and search, at random or announced times, packages, boxes, clothing, personal belongings, motor vehicles and watercraft brought onto company property or property where the company has authorized access, in accordance with the company security plan. I consent to and agree to cooperate with such inspections.

I consent to the searches described above.

Typed signaturePrinted nameDate

HIPAA Authorization

Complete all applicable sections. Enter N/A where a section does not apply.

Patient/Plan Member

Last nameFirst nameMiddle nameReference numberDate of birthAddressCity/State/ZIP

Authorized to Disclose PHI

NameAddressCity/State/ZIP

Authorized to Receive PHI

NameRelationshipTelephoneAddressCity/State/ZIP

Expiration

Expiration eventExpiration date

Information to be Disclosed

Medical records Dental records Other

Other details Specific information details

Purpose

Additional conditions I understand the authorization, my right to revoke it in writing, and my right to receive a copy.

Patient/plan member printed nameTyped signatureDateName of signatory if not patientAuthority to signTranslator name, if applicable

Step 4 of 6

Adult Medical History Questionnaire

Complete truthfully to the best of your knowledge.

General Information

NameDate of birthAgeGenderAddressCity/State/ZIPForm date

Emergency Contact

NamePhoneAddressCellPrimary care providerProvider phone

Past Medical History

Other or explanation

Do you wear glasses?

Yes No

Do you wear contacts?

Yes No

Past Surgical History

List procedure dates and details

Current Medications and Drug AllergiesCurrent or recent medications, including dosage No medicationsDrug allergies and reactions No known drug allergies

Skeletal Injuries in the Past Two Years

Social History

Alcohol useAlcohol amount/typeAge quit, if formerTobacco useTobacco amount/typeAge quit, if former

Lives alone Prior/current recreational drug use Other HIV risk factors

Explanation and occupation

Review of Systems

Check symptoms currently present or experienced within the past two years.

Medical Certification

The questions on this form have been answered completely and truthfully to the best of my knowledge.

Employee typed signatureDate

Step 5 of 6

Employment Eligibility (Form I-9)

Section 1 must be completed no later than the first day of employment, but not before accepting a job offer.

Compliance note: This online worksheet helps collect the information, but the employer must retain a properly completed current USCIS Form I-9 and follow all document inspection and electronic-signature requirements.

Section 1 - Employee Information and Attestation

Last nameFirst nameMiddle initialOther last names usedAddressApt. numberCity or townStateZIPDate of birthU.S. Social Security numberEmailTelephone

A citizen of the United States A noncitizen national of the United States A lawful permanent resident An alien authorized to work

USCIS or A-numberWork authorization expirationForm I-94 numberForeign passport numberCountry of issuance

I attest, under penalty of perjury, that the information entered is true and correct.

Employee typed signatureToday's date

Document Uploads for Employer Review

Upload clear images or PDF copies for office review. The employer must still inspect original documents as required.

List A document(s)

OR

List B documentList C document

Employer Section (Office Use)

Document titleIssuing authorityDocument numberExpiration dateFirst day of employmentRepresentative name and titleRepresentative signatureReview date

Step 6 of 6

Review and Submit

Review the application, then email the completed PDF to the Superior Bay Marine office.

Final Acknowledgment I confirm that I reviewed this application and that the information is complete and accurate to the best of my knowledge. *

Final typed signature *Date *

The completed PDF will be sent to tim@superiorbaymarineofal.com. Uploaded I-9 support documents will be attached when size limits allow.