M&P BARGE CO, INC.

APPLICATION FOR EMPLOYMENT

It is the policy of M&P Barge Co, Inc. to provide equal opportunity in employment and
advancement to all persons without regard to race, color, religion, age, gender/sex, national
origin, disability or any other protected status under state and federal law.

(PLEASE PRINT)

Position Applied for ___________________________________ Date: ___________________

PERSONAL INFORMATON

Last Name: First Name: MI: Social Security #

Address: City: State: Zip Code

Home Phone #: Cell Phone #: Email Address

__________________________________________________
Driver’s License Number:
Are you 18 years of age or older? Yes No

Are you Currently Employed? Yes No

EMPLOYMENT EXPERIENCE

Please state the names of your present and all previous employers in chronological order. If you have
been self-employed, or are currently self-employed, please give the name of your firm, company or
operations.

Employer:_____________________________Employer Phone Number:__________________________

Address:______________________________________________________________________

Job Title:______________________________Supervisor:_______________________________

Reason for leaving: ___________________ Work performed:____________________________

Dates: From: ________________________To:_________________________

Starting Wage: $_____________________ Final Wage: $______________________________

 Employer:_____________________________Employer Phone Number:__________________________

Address:______________________________________________________________________

Job Title:______________________________Supervisor:_______________________________

Reason for leaving: ___________________ Work performed:____________________________

Dates: From: ________________________To:_________________________

Starting Wage: $_____________________ Final Wage: $______________________________

Employer:_____________________________Employer Phone Number:__________________________

Address:______________________________________________________________________

Job Title:______________________________Supervisor:_______________________________

Reason for leaving: ___________________ Work performed:____________________________

Dates: From: ________________________To:_________________________

Starting Wage: $_____________________ Final Wage: $______________________________

Have you ever been convicted of a felony or misdemeanor? Yes No

(Note : An individual will not be denied employment solely because of a felony conviction, but all circumstances must be considered)

If yes, please give the date, state, and county of said conviction and all circumstances and
details involving said conviction: _________________________________________________
____________________________________________________________________________
___________________________________________________________________________

Do you have a valid Transportation Worker Identification Credential(TWIC) card?: Yes No

If No, Have you applied for your Transportation Identification Credential Card (TWIC) card?:
Yes No
 EDUCATION:

Please list all schools and technical training you have received: (Please Print)
SCHOOL NAME & YEARS COMPLETED DIPLOMA/DEGREE COURSE OF STUDY
ADDRESS CIRCLE ONE
High School
9 10 11 12

College/University
1234

Vocational/Technical
1234

Describe all other training, experience, skills & special educational experiences: (Please
Print)

Describe any job-related training received in the United States military: (Please Print)

REFERENCES
Please state the name, address & telephone numbers of 3 references who are unrelated to you. (Please Print)

NAME ADDRESS PHONE NUMBER

Do you understand the requirements of the job for which you are applying? Yes No

Can you perform the requirements of this job with or without reasonable accommodation? Yes No
APPLICATION WAIVER FORM
(To be signed by all job applicants along with application form)

I certify that the information contained in this application is correct to the best of my knowledge
and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal.
I authorize any of the persons or organizations referenced in this application to give you any
and all information concerning my previous employment, education, or any other information they
may have, personal or otherwise, with regard to any of the subjects covered by this application and
release all such parties from all liability for any damage that may result from furnishing such
information to you. I authorize you to request and receive such information.
In consideration for my employment and my being considered for employment by your
company, I agree to conform to the rules and regulations of the company and acknowledge that
these rules and regulations may be changed, interpreted, withdrawn, or added to by your company
at any time, at the company’s sole option and without prior notice to me. I further acknowledge that
my employment may be terminated, and any offer of employment, if such is made, may be withdrawn,
with or without prior notice, at any time, at the option of the company or myself.
I understand that no representative of the company has any authority to enter into any
agreement for employment for any specific period of time, or assure or make some other personnel
move, either prior to commencement of employment or after I have become employed, or to assure
any benefits or terms and conditions of employment, or make any agreement contrary to the
foregoing.
I acknowledge that I have been advised that this application will remain active for no more
than 90 days from the date it was made.

________________________________ _____________________________
Signature of Applicant Date
__________________________________ _____________________________
Signature of Company Representative Date
 VESSEL PERSONNEL PHYSICAL REQUIREMENTS

Captain / Mates:
1. Must climb ladders
2. Must perform moderate lifting.
3. Must be able to keep footing in sea conditions.
4. Position involves frequent standing.
Note: This individual may be accommodated.
Deckhand:
1. Must climb ladders.
2. Must perform heavy lifting.
3. Is required to engage in strenuous pulling.
4. Must be able to keep footing in sea conditions.
5. Position involves frequent standing.
Note: This individual may not be accommodated.
 M&P BARGE CO, INC.
Authorization & Release Form - Drug & Alcohol Testing
(To be completed by applicant)

To the previous employer of _____________________ SS# __________________ , pursuant to

U.S. Department of Transportation (DOT) 49 CFR 40.25, you are authorized to release all
documentation concerning drug & alcohol testing during my employment with you to M&P Barge Co,
Inc. You are held harmless for the release of this information when used in compliance with 49 CFR
40.25.

Applicant’s Printed Name Applicant’s Signature

Request for Information

(To be completed by previous employer)

The above individual has applied for employment with M&P Barge Co, Inc., a marine employer.
Under 49 CFR 40.25, we request the following information to proceed with this application:

During this Applicant's employment with you, was this Applicant subject to DOT regulations?
● If “No” return the form as directed at the bottom of page.
● If “Yes” answer the following questions before returning this form.

During this Applicant’s employment with you, has he/she:

1. Ever tested 0.04 or higher on an alcohol test? Yes No
2. Ever had a verified positive drug test? Yes No
3. Ever refused to be tested for drugs or alcohol? Yes No
4. Ever violated any other DOT drug or alcohol regulation? Yes No
5. If the applicant has ever violated a DOT drug and/or alcohol regulation,
can you supply documentation of the employees successful completion Yes No
of the DOT’s required “Return to Duty” process?

Company Name Date

Signature Title

Return to: M&P Barge Co, Inc. Fax: (225) 385-4137

29060 Hwy 75, Email: carlie@mpbarge.com
Plaquemine, LA 70767