Date:_____________   Position Applying for:________________________

Name:______________________________________________________

Pres.Address:______________________________City & State______

Phone #:_____________________  Are you over 18 yrs of Age?_Yes __No

Are you a U.S. Citizen?__Yes __No

Present Employer:____________________________________________

Are any restrictions on your Driver’s License? ____Yes  ____No  
If so, explain_________________________________________________
___________________________________________________________

Has your license ever been revoked? ___Yes ___No     If so, what reason?______________________________________________________________________________________________________________________

Have you ever been convicted of DUI? ___ Yes  ___No 
If so, when & where ___________________________________________

U.S. Coast Guard Maritime Documents – List in detail: ___________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________

Have you ever had any Coast Guard license or document suspended and/or revoked?  ___Yes ___No

If so, explain: ___________________________________________________________

______________________________________________________________________________________________________________________

Have you ever been convicted of a felony? ____Yes  ____No  If so, explain ___________________________________________________________ ______________________________________________________________________________________________________________________

Where were you prosecuted? ___________________________________________________________

Are you currently serving time or on probation?  _____Yes  ____No

Are you currently being prosecuted for an alleged felony? ____Yes  ____No