The Great Lakes Group

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 Contacts Telephone Number (including area code)
12. Second Emergency Contacts 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)
Yes
No
13. Emergency Contacts 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
Day
Year
20. Which position are you applying for? (Check all that apply)
(Check all that apply)
apply)
The Great Lakes Towing Company
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)
__________________
(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
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
No
If NO, go to block 21(g)
21(d) College/University
Name of College/University School
Month and Year Attended

Month
Year
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
The Great Lakes Group

Revised 5/2012
Page 2
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
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
Name of School
City

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
Name of School
City

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
Name of School
City

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
Name of School
City

Month
Year
Class Room
Hours
State
Subject(s)
ZIP Code
Training Completed
(Check Box)
Yes
No

Revised 5/2012
Page 3
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
Month
Year
To
22(f) Name of Present or Last Supervisor
(First)
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

Revised 5/2012
Page 4
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
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
Month
Year
To
22(p) Name of Prior Supervisor
(First)
22(q) Telephone Number

(Last)
Area Code
Prefix
Last 4 Numbers
22(r) Salary History (Last salary held)

Per (Check One):

Hour
Day
Month
Year
22(s) Duties Performed
22(t) Reason for Leaving

Revised 5/2012
Page 5

22(u) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment?
Yes
No
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
Month
Year
To
22(z) Name of Prior Supervisor
(First)
23(aa) Telephone Number

(Last)
Area Code
Prefix
Last 4 Numbers
22(bb) Salary History (Last salary held)

Per (Check One):

Hour
Day
Month
Year
22(cc) Duties Performed
22(dd) Reason for Leaving

Revised 5/2012
Page 6

22(ee) Do you authorize the Company to contact your present or last employer regarding your character, qualifications, and record of employment?
Yes
No
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
Month
Year
To
22(jj) Name of Prior Supervisor
(First)
22(kk) Telephone Number

(Last)
Area Code
Prefix
Last 4 Numbers
22(ll) Salary History (Last salary held)

Per (Check One):

Hour
Day
Month
Year
22(mm) Duties Performed
22(nn) Reason for Leaving

Revised 5/2012
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

Revised 5/2012
Page 8
24. Professional, Educational or Civic Organizations

(List memberships as indicated. You may exclude those which may disclose your race, color, religion or national origin)
24(a) Name of Organization
City
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
24(e) Name of Organization
City
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
24(i) Name of Organization
City
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.

Revised 5/2012
Page 9
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

Revised 5/2012
Page 10
Item No.
Month & Year
Explanation
Mailing Address
Item No.
Month & Year
Explanation
Mailing Address
Item No.
Month & Year
Explanation
Mailing Address
Item No.
Month & Year
Explanation
Mailing Address
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
No
(ii)
Can you submit proof of legal employment authorization and identity as required by governmental authorities?
Yes
No
(iii)
Are you under eighteen (18) years of age?
(iv)
Can you perform any or all job functions for the position applied for, with or without reasonable accommodation? Yes
No
Yes
No

Revised 5/2012
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.
(b)______
Initial

Revised 5/2012
Page 12
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.
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.
(g)______
Initial
(h)______
Initial
I represent and warrant that I have read and fully understand the foregoing and that I seek employment
under these conditions.
Applicants Signature __________________________________________________________________
ADMINISTRATIVE (Including Management and Clerical) STOP HERE UNLESS A VETERAN:
If a Veteran - Complete Part IV (Optional)

Revised 5/2012
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
Document? Yes
No
(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) ______________________________________
____________________________________________________________

Revised 5/2012
Page 14
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
2 - Indicates that you have used/performed alone with little
1 - Indicates that you have trained, but never had work experience
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
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
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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
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Revised 5/2012
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:
_____
_____
_____
_____
_____
_____
_____
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_____
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_____
_____
_____
_____
_____
_____
_____
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_____
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_____
_____
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
_____
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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
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

Revised 5/2012
Page 16
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
Yes
No
Other (Specify)______________
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
Date of Signature: Month, Date & Year

Revised 5/2012
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

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

45(e) Name of Contact Person (First & Last Name)
45(g) Dates of Prior Employment: Month & Year
Month & Year

TO

Revised 5/2012
Page 18
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

Revised 5/2012
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 veterans 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 ADAs 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 DOLs 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
Date of Signature (Month, Day & Year)

Revised 5/2012
Page 20

Revised 5/2012
Page 21

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For Puerto Rico:

ATTN: Human Resources

For Great Lakes:

Part I (to be completed by all applicants);

(Month) (Date) (Year)

3. Social Security Number

4. Home Telephone Number (including area code)

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

7(b) Expiration Date (Month, Day, Year)

8. Are you a U.S. Citizen

(including area code)

8(a) If No, Do you have a Current

11. Emergency Contacts Telephone Number (including area code)

12. Second Emergency Contacts Telephone Number (including area

8(b) If Yes, Country of Issue

8(c) Expiration Date (Month, Day, Year)

9. Do You Have a Passport?

13. Emergency Contacts E-Mail Address

14. Birth Place: (City)

15. Present Mailing Address

16. Permanent Mailing Address (Indicate "same" if same as block 15.)

17. Date Available to Start Work

18. Which Company are you

19. Location Preference

(Check all that apply)

Puerto Rico Towing & Barge Co.

Great Lakes Ports

Soo Linehandling Services, Inc.

Sault Ste. Marie, MI

If specific port(s) are

(a) Vessel Afloat

(b) Vessel Ashore

(c) Office Position

21. Education and Training

Years Completed (Check)

21(b) Did you receive a diploma?

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

If NO, go to block 21(g)

Month and Year Attended

Number of Credit Hours Completed

Month and Year of Degree