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Notice of Interest

ONLY APPLICANTS WHO MEET THE MINIMUM REQUIREMENTS WILL BE CONSIDERED.

*	Asterisked fields are required.

*	First Name :
	Middle Initial :
*	Last Name :

*	Address :
*	City :
*	State :
*	Zip :
*	Phone :
	Email :

	Please Complete the following if interested in a vessel position:
*	STCW :	Yes No
*	License :	Yes No
	(if Licensed, please list)

*	Maritime Academy:

	List any relevant Towing experience (years, location)

Voluntary Affirmative Action Information

Decline Survey.

All applicants are treated equally without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status.

As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.

The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

Referral Source :
Advertisement Employee Employment Agency Self Union School Other
Name of Source if Applicable :

Check One : Male Female

Black	All person having origins in any of the Black racial groups of Arfica.
Hispanic	All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture, regardless of race.
Asian	All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.
Native American	All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. (Meets Bureau of Indian Affairs definition standards).
White	(Or Not Covered Above)

Check One, if Applicable:
Special Disable Veteran (Receives 30% disability)
Vietnam Era Veteran (Republic of Vietnam service between 2/28/61 & 5/7/75; or Military service between 8/5/64 & 5/7/75).
Individual with a disability


Copyright 2003 Crowley Maritime Corporation