FLORIDA MARINE TRANSPORTERS, INC.

PBC MANAGEMENT, INC.

IMPORTANT NOTICE
In order for PBC Management, Inc. to properly process your application,
please refer to the following:

The entire application must be completed and include the name, city, state, dates of
employment and phone numbers of each employer for which you have worked. The
application must be completed by the applicant only. No one else should write on
this application,

FAILURE TO PROVIDE ALL REQUIRED INFORMATION OR

TO FOLLOW INSTRUCTIONS MAY CAUSE YOUR
APPLICATION TO BE REJECTED.

INCLUDE A COPY OF THE FOLLOWING DOCUMENTS WITH YOUR

APPLICATION:

1. Valid Driver’s License (Picture I.D. is not sufficient)

2. Social Security Card
3. Birth Certificate (not necessary if you furnish # 2)
4. Any United States Coast Guard document or license you have

**If an applicant qualifies for an interview, he or she must provide the original
documents from the list above. **

Please mail or fax the COMPLETED application with COPIES of the above
documents to the following address:

Florida Marine Transporters, Inc.

PBC Management, Inc.
Attn: Human Resources
2360 5th Street
Mandeville, LA 70471
Phone (985) 629-2082
Fax (985) 629-2110
 APPLICATION FOR EMPLOYMENT
(PRE-EMPLOYMENT QUESTIONNAIRE/AN EQUAL OPPORTUNITY EMPLOYER)

PERSONAL INFORMATION

NAME_________________________________________________________ DATE__________________________
LAST FIRST MIDDLE

PRESENT ADDRESS_____________________________________________________________________________________
STREET CITY STATE ZIP
PERMANENT
ADDRESS______________________________________________________________________________________________
STREET CITY STATE ZIP

SOCIAL SECURITY NUMBER__________________________________ EMAIL___________________________________

HOME PHONE: ___________________________________ CELL PHONE: __________________________________

ARE YOU 18 YEARS OF AGE OR OLDER? YES__________NO__________
ARE YOU PREVENTED FROM LAWFULLY BECOMING EMPLOYED
IN THIS COUNTRY BECAUSE OF VISA OR IMMIGRATION STATUS? YES__________NO__________

EMPLOYMENT DESIRED
DATE YOU SALARY
POSITION_________________________________ CAN START_________________ DESIRED_______________
IF SO, MAY WE INQUIRE OF
ARE YOU EMPLOYED NOW? ________________ YOUR PRESENT EMPLOYER? ____________________________
EVER APPLIED TO THIS COMPANY BEFORE? __________WHERE? __________________WHEN? ___________________
REFERRED BY _________________________________________________________________________________________

EDUCATION NAME AND LOCATION NO. OF DID YOU SUBJECTS

OF SCHOOL YEARS GRADUATE? STUDIED
ATTENDED

GRAMMAR
SCHOOL

HIGH SCHOOL
(OR GED)

COLLEGE

TRADE, BUSINESS
OR
CORRESPONDENCE
SCHOOL

GENERAL
SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK:______________________________________________________
________________________________________________________________________________________________________
SPECIAL SKILLS:________________________________________________________________________________________
ACTIVITES (CIVIC, ATHLETIC, ETC.):_____________________________________________________________________
EXCLUDE ANY ORGANIZATION IF ITS NAME INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OF
ORIGIN OF ITS MEMBERS.

HAVE YOU EVER SERVED

IN THE MILITARY SERVICE OF THE U.S.? YES________ NO________ BRANCH OF SERVICE? __________________
ARE YOU ABLE TO PERFORM THE REQUIREMENTS OF THE JOB? YES_____ NO_____
 Do you have a valid driver’s license? Yes______ No______ State _____________ License No._________________
Has your Tankerman’s Ticket ever been suspended? Yes________ No__________ Year ________ N/A_______
Has your Pilot’s License ever been suspended? Yes________ No__________ Year ________ N/A_______
Has your driver’s license been revoked, restricted or suspended within the past 10 years? Yes_______ No________
Have you been convicted of driving under the influence (D.U.I.) within the past 10 years? Yes_______ No________
Have you been convicted of a crime or pleaded nolo contendere (no contest) to a criminal offense (other than traffic
violations) in the past 10 years? Yes_______ No_______
If the answer to any of the items above is “yes”, please explain all occurrences in detail and complete the information in the
chart below. If necessary, use the back or attach additional sheet(s):
**A failure to disclose any criminal convictions could result in the withdrawal of an employment offer**

NAME (at time of DATE CRIMINAL LAW AGENCY DISPOSITION

conviction or plea) CONVICTION (status)

*NOTE: A “YES” RESPONSE DOES NOT AUTOMATICALLY DISQUALIFY AN APPLICANT FOR EMPLOYMENT.

FORMER EMPLOYERS (LIST LAST FOUR EMPLOYERS OR 12 PREVIOUS YEARS STARTING WITH MOST RECENT FIRST)

Employer Name:______________________________________ Phone Number:____________________________________

City & State:_________________________________________ Position:_____________________________________
Dates of Employment Reason for
From:_____________To:_____________ Leaving:____________________________________________________
____________________________________________________________________________________________________________
________________________________________________ Name of Supervisor: _________________________________________

Employer Name:______________________________________ Phone Number:__________________________________

City & State:_________________________________________ Position:____________________________________
Dates of Employment Reason for
From:_____________ To:_____________ Leaving:___________________________________________________
__________________________________________________________________________________________________________
_________________________________________________ Name of Supervisor: ______________________________________

Employer Name:______________________________________ Phone Number:__________________________________

City & State:_________________________________________ Position:____________________________________
Dates of Employment Reason for
From:_____________ To:_____________ Leaving:___________________________________________________
__________________________________________________________________________________________________________
_________________________________________________ Name of Supervisor: _______________________________________

Employer Name:______________________________________ Phone Number:_________________________________

City & State:_________________________________________ Position:___________________________________
Dates of Employment Reason for
From:_____________ To:_____________ Leaving:__________________________________________________
__________________________________________________________________________________________________________
________________________________________________ Name of Supervisor: _______________________________________
WHICH OF THESE JOBS DID YOU LIKE BEST? _____________________________________________________________
WHAT DID YOU LIKE THE MOST ABOUT THIS JOB? ______________________________________________________
REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU WHOM YOU HAVE KNOWN AT
LEAST ONE YEAR.

NAME PHONE NUMBER BUSINESS YEARS ACQUAINTED

1.

2.

3.

THE FOLLOWING STATEMENT APPLIES IN: MARYLAND & MASSACHUSETTES. IT IS UNLAWFUL IN

THE STATE OF ______________________________ (FILL IN NAME OF STATE) TO REQUIRE OR
ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED
EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL
PENALTIES AND CIVIL LIABILITY.
________________________________________
SIGNATURE OF APPLICANT

IN CASE OF
EMERGENCY NOTIFY___________________________________________________________________________________
NAME RELATIONSHIP

___________________________________________________________________________________
ADDRESS PHONE NUMBER

CERTIFICATION:
I certify that all the information submitted on this application is true and complete. I understand that if any false
information, omissions or misrepresentations are discovered, my application may be rejected. If I am employed,
my employment may be terminated at any time for the same reason.

I acknowledge that if hired, I will be expected to conform to company rules and regulations, and I will be an at-
will employee, whose employment and compensation can be terminated with or without cause, at the discretion
of the employer or employee. I also understand that the company may change with or without cause and with or
without notice the terms and conditions of my employment at any time. I understand that no company
representative other than its chief executive officer or president (agreement must be written and signed) has any
authority to enter into an agreement for employment for a specific period of time or to make an agreement
contrary to the foregoing.

I understand that Florida Marine Transporters/PBC Management has a drug and alcohol policy that provides for
pre-employment drug and alcohol testing as well as testing after commencement of employment as a condition
of employment or continued employment. I hereby give my consent to said testing and the release of the results
to Florida Marine Transporters/PBC Management.

I understand that the submission of this application for employment to Florida Marine Transporters/PBC
Management does not create a promise of employment or the creation of any employment relationship. I further
understand that in submitting this application that it will be considered active for no more than thirty days. If I
intend to be considered for employment thereafter, I must reapply for a position with this company.
I understand that if I have any disability that prevents me from performing my job duties, I am to notify PBC
Management, Inc. and/or Florida Marine Transporters, Inc. by notifying the Human Resources Department of
my disability so that PBC Management, Inc. and/or Florida Marine Transporters, Inc. can begin a dialogue with
me to determine, with my input, whether any reasonable accommodations can be made to allow me to perform
the essential functions of the position for which I am applying.

I further understand that, out of a concern for my safety, the safety of others, and as a matter of sound hiring
practices, PBC Management, Inc. and Florida Marine Transporters, Inc. will require that I submit, after I am
offered a position, to a post-offer employment physical examination to determine whether I can perform
essential functions of any position for which I might be placed and that this determination is material to the
decision of PBC Management, Inc. and/or Florida Marine Transporters, Inc. of whether to hire me for a
particular position. I understand that essential functions of some positions may include lifting heavy objects,
regular attendance, working certain schedules and shifts, travel, regular and predictable attendance, working
overtime hours, travel to/from a vessel at the beginning or end of a hitch, and other requirements.

I understand that no employment relationship exists between me and PBC Management, Inc. and/or Florida
Marine Transporters, Inc. before I have submitted to the post-offer, pre-employment physical examination and
before PBC Management, Inc. and/or Florida Marine Transporters, Inc. have received a physician’s final report
that confirms that I am capable of performing the essential functions of the position for which I am applying,
with or without a reasonable accommodation, and for which PBC Management, Inc. and Florida Marine
Transporters, Inc. have an opening.

I acknowledge that I have been given a description of the physical requirements and the job duties for the
position that I am seeking.

I UNDERSTAND THAT FAILURE TO ANSWER TRUTHFULLY TO ANY INQUIRIES ABOUT MY

PREVIOUS INJURIES, ILLNESSES, MENTAL OR PHYSICAL CONDITIONS, OR OTHER
MEDICAL CONDITIONS, WHETHER ON THIS APPLICATION OR OTHER MEDICAL
QUESTIONNAIRE OR FORM, OR BEFORE OR DURING MY PHYSICAL EXAMINATIONS, MAY
RESULT IN THE IMMEDIATE TERMINATION OF MY EMPLOYMENT AND MAY RESULT IN
THE FORFEITURE OF WORKERS’ COMPENSATION BENEFITS UNDER LSA-R.S. 23:1208.1, AS
WELL AS FORFEITURE OF CERTAIN EMPLOYMENT BENEFITS, MEDICAL TREATMENT,
COMPENSATION BENEFITS, AND/OR MAINTENANCE AND CURE BENEFITS.

In signing this application and other included forms, I swear and affirm that all of my responses are true and
accurate. I also acknowledge that this employment application is not a mere formality, and that accurate and
truthful responses are important to PBC Management, Inc. and Florida Marine Transporters, Inc. These
companies will rely upon the information included on my application to evaluate placing me in a particular
company position. Finally, I acknowledge that I am not relying on any other promises or assurances regarding
the information sought in my application.

I have read and understand the foregoing statements contained in this section.

DATE______________________ SIGNATURE_____________________________________
 NOTICE TO APPLICANTS/EMPLOYEES REGARDING CONSUMER REPORTS

A consumer report and/or an investigative consumer report including information concerning your
character, employment history, general reputation, personal characteristics, criminal convictions
records, education, qualifications, motor vehicle record, mode of living, and/or credit and indebtedness
may be obtained in connection with your application for and continued employment with the company.
A consumer report and/or an investigative report may be obtained at any time during the application
process or during your employment with this company. A consumer report containing injury and
illness records and medical information may be obtained after a tentative offer of employment has
been made. Upon timely written request of the Human Resources Department of the company; and
within five days of the request, the name, address and phone number of the reporting agency and the
nature and scope of the consumer report will be disclosed to you.

Before any adverse action is taken; based in whole or in part on the information contained in the
consumer report, you will be provided a copy of the report, the name, address and telephone number of
the reporting agency, a summary of your rights under the Fair Credit Reporting Act, as well as
additional information on your rights under the law.

CONSENT TO OBTAINING CONSUMER REPORTS – READ BEFORE SIGNING

1) I HAVE READ THE “NOTICE TO APPLICANTS/EMPLOYEES REGARDING

CONSUMER REPORTS” AND HEREBY AUTHORIZE THE COMPANY TO OBTAIN
CONSUMER REPORTS AND/OR INVESTIGATIVE CONSUMER REPORTS AS
DESCRIBED. I UNDERSTAND THAT I HAVE THE RIGHT TO MAKE A WRITTEN
REQUEST WITHIN A REASONABLE AMOUNT OF TIME TO RECEIVE ADDITIONAL,
DETAILED INFORMATION ABOUT THE NATURE AND SCOPE OF ANY
INVESTIGATIVE REPORT OR OTHER CONSUMER REPORTS THAT ARE MADE,
INCLUDING THE NAME, ADDRESS AND TELEPHONE NUMBER OF THE
CONSUMER REPORTING AGENCY.

2) I HEREBY AUTHORIZE ANY PRESENT OR FORMER EMPLOYERS, CONSUMER

REPORTING AGENCIES, EDUCATIONAL INSTITUTIONS, CRIMINAL JUSTICE
AGENCIES, DEPARTMENTS OF MOTOR VEHICLES, PUBLIC AGENCY, FINANCIAL
INSTITUTIONS, OR ANY OTHER PERSON OR AGENCY HAVING KNOWLEDGE OF
ME TO SUBMIT INFORMATION OR OPINIONS ABOUT MYSELF, INCLUDING DATA
RECEIVED FROM OTHER SOURCES, IN ORDER THAT MY EMPLOYMENT
QUALIFICATIONS MAY BE EVALUATED. I HOLD SAID PERSONS AND/OR
ORGANIZATIONS BLAMELESS AND WITHOUT LIABILITY FOR STATEMENTS OR
OPINIONS MADE REGARDING MY CHARACTER, EXPERIENCE OR
QUALIFICATIONS.

BY MY SIGNATURE BELOW, I ACKNOWLEDGE THAT I HAVE READ AND

UNDERSTOOD ALL OF THE ABOVE STATEMENTS.
______________________________ ______________________________
PRINT YOUR NAME SIGNATURE
______________________________
DATE
 FLORIDA MARINE TRANSPORTERS, INC.
PBC MANAGEMENT, INC.

Chemical Testing Results Release Authorization

To Whom It May Concern:

I, ___________________________, have applied for employment with Florida

Marine Transporters, Inc. (FMT) and have authorized FMT to obtain any and all

chemical testing information required by 49 CFR Part 40 (DOT Regulations)

from your company.

Signature: ____________________________

Printed Name: ____________________________

Social Security #: ____________________________

Date: ____________________________