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APPLICANT INFORMATION
Position Applying For
Date
Social Sec #
First Name
Last Name
M.I.
Address
City
Zip Code
State
Telephone
No
Yes
Yes
No
No
Yes
Year(s)
(Name)
Are you able to perform the essential job functions of the position for which you are applying?
(Relationship)
Yes
No
Location
Did you
Graduate?
Major
Degree Obtained
No Selection
No Selection
No Selection
Yes
No
If yes, when?
Hours attending
ADDITIONAL SKILLS/ABILITIES/KNOWLEDGE
List other job-related special training, certifications, skills, etc. that should be considered for placement. (Please
Entered by
exclude those that indicate age, race, color, national origin, religion or disability.)
Entered @ AP Date
Letter/Date
@ AP Updates
Interviewer
Interview Date
UniSea Group companies may require as a condition of employment all employees to agree to provide urine, saliva or other
samples to be used for analysis of drug use under circumstances of pre-employement or as deemed necessary by company
management. In addition, all employees covered by the United States Coast Guard Regulations will be required to submit
urinalysis under circumstances set out in the U.S.C.G. Regulations relating to serious marine accidents and testing programs.
to
UniSea, Inc. ~ 15400 NE 90th Street ~ P.O. Box 97019 ~ Redmond, WA 98073-9719 ~ Employment Line: (425) 861-5330
EMPLOYMENT HISTORY
List past and present employment, beginning with most recent. Please include part-time, summer and volunteer positions, and relevant U.S.
military experience. Please complete in full.
Social Sec #
Employed From
No
Starting Position
Starting Salary
F.T
Address
City
State
Ending Salary
Ending Position
F.T.
P.T.
P.T.
May we contact?
No Selection
Responsibilities and Accomplishments
Reason for Leaving
Employed By:
Address
Employed From
City
State
Starting Position
Starting Salary
F.T
P.T.
F.T.
P.T.
Ending Salary
Ending Position
May we contact?
No Selection
Responsibilities and Accomplishments
Reason for Leaving
Employed By:
Address
Employed From
City
State
Starting Position
Starting Salary
F.T
P.T.
F.T.
P.T.
Ending Salary
Ending Position
May we contact?
No Selection
Responsibilities and Accomplishments
Reason for Leaving
Employed By:
Address
Employed From
City
State
Starting Position
Starting Salary
F.T
P.T.
F.T.
P.T.
Ending Salary
Ending Position
May we contact?
No Selection
Responsibilities and Accomplishments
Reason for Leaving
During the past seven years, have you been convicted of, or released from prison for any felony?
Yes
No
The above statement(s) are true and accurate. I understand that any misrepresentation or omission of facts is cause for dismissal. I hereby authorize UniSea Group to investigate
any and all statements contained herein and request the persons, firms or corporations named above to answer any and all questions relating to this application and any employment based thereon. I hereby release from all liability UniSea Group and any person, firm or corporation who provides information concerning my prior education, employment
or character. If employed, I understand that my employment is an employment at will and may, regardless of the date my wages and salary are paid, be terminated at any time
without prior notice.
Signature of Applicant
Date