Welcome to the Jantran Application Form!

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Phone: (662) 759 - 6841

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First Name

Last Name

Last 4 of SSN

Position

First Name

Middle

Last Name

Email

Date of Birth*

SSN

Mobile Number

Other Number

Have you ever made an application to this company before?

Yes No

Have you ever been employed by this company before?

Yes No

Have you ever been convicted of a crime?**

Yes No

Explain:

Present Address

Street

City

State

Zip

Permanent Address

Street

City

State

Zip

* The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40, but less than 70 years of age.

** Conviction of a crime is not an automatic bar to employment. All circumstances will be considered and kept confidential.

Grade School

High School

Tech School

College Education

Graduate School

Do you have any Vocational Training?

Vocational Training

School Name

Course Name

Date Completed

Awards Certificates/Spec. Skills

Have you served in the Military?

Military Training

Branch Name

Enlistment Date

Discharge Date

Rating at Discharge

Type of Discharge

Special Training

Please list 3 References

Reference

Reference Name

Street

City

State

Zip

Phone

Relationship

Please fill out your employment history.

Employment History

Employer

Phone

Street

City

State

Zip

Job title

Deparment/Vessel

Supervisor

DATES

From

SALARY

Starting

Final

Describe Major Duties

IF APPLICABLE: HORSEPOWER

REASON FOR LEAVING

Have you worked for a department of transportation employer (Trucking, Rail or Marine Company) within the previous 2 years?

Employment History

Company Name

DATES

From

RELEASE FOR OBTAINING PRIOR DRUG & ALCOHOL TESTING RESULTS

Under Department of transportation (DOT) regulations (49 CFR Part 40 - Procedures for Transportation Workplace Drug and Alcohol Testing Programs) all applicants for maritime employment must sign a release requiring past DOT employers to provide drug and alcohol testing results for the prior two years.

Under these regulations, refusal to sign this release prohibits the company from considering you for employment for any safety sensitive marine position.

I hereby authorize you to release to JANTRAN, INC. all my drug and alcohol testing for the past two years.

I release you (the custodian of such records) and any other agency, including officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request to release information or any attempt to comply with it. The authorization is void if not exercised within one (1) year from the date of signing. I agree that a photographic copy of this authorization is as valid as the original.

Your signature will be used here if accepted.

PREVIOUS MARINE EXPERIENCE AND DOCUMENTATION

Do you have previous marine Experience or documentation?

Yes No

U.S. Coast Guard Maritime Document

Yes No

Serial Number

Rating (Grade)

Issue Date

Location

FCC Radio License?

Yes No

Serial Number

Issue Date

Vessel Operators (License to operate uninpsected towing vessels-minimum requirement)

Master of Towing Vessel

Mate of Towing Vessel

Operator of Uninspected Towing Vessel (OUTV)

Other list type

Serial Number

Expiration

Issued

Location

LIST BELOW ROUTES YOU ARE EXPERIENCED IN VESSEL OPERATION

Intracoastal

From

Port Allen Route

From

Atchafalaya River

From

Upper Mississippi

From

Warrior River

From

Missouri River

From

Ohio River

From

Cumberland River

From

Illinois River

From

Tennessee River

From

Tenn.-Tom River

From

List Tow Experience

No. Of Barges

Width

Length

Radar Endorsement

Type of Endorsement

Issue Date

Expiration Date

Issue Location

Vessel Engineers

Limited Horsepower

Unlimited Horsepower

Chief

Assistant

List the Makes of Engines & Auxiliary Equipment Operated

Designated Duty Officer

Yes No

Issue Date

Horsepower

Employment History

Dates Operated

From

Make Of Engine/Auxiliary Operated

Horsepower

APPLICATION QUESTIONNAIRE
(Please check Yes or No)

Are you at least 18 years old?

Yes No

Do you have a valid drivers license?

Yes No

Are you currently working?

Yes No

Will you have to give a (2) week notice?

Yes No

Are you willing to work 30 consecutive days a month away from your family?

Yes No

Can you pass a drug and alcohol screen?

Yes No

Do you have 20/20 to 20/40 corrected vision?

Yes No

Are you color blind?

Yes No

Are you hearing impaired or think that you might be?

Yes No

Have you ever temporarily worked away from home?

Yes No

Have you ever had any criminal issues while working away from home?

Yes No

Do you have an original birth certificate or certified copy?

Yes No

Do you have a social security card?

Yes No

Do you have a bank account?

Yes No

Do you have a twic card?

Yes No

Have you ever experienced a work related injury?

Yes No

Explain

Have you ever been operated on?

Yes No

Explain

Have you ever missed time from work due to an injury?

Yes No

Explain

Have you ever undergone an MRI or CT scan?

Yes No

Explain

Have you ever received a disability rating?

Yes No

Explain

Have you ever been limited in the amount of weight that you can lift by a physician?

Yes No

Explain

Have you ever failed a physical or been denied employment due to any injury or illness?

Yes No

Explain

APPLICANT DRUG & ALCOHOL SCREEN AND SEARCH AUTHORIZATION FORM

I, , authorize JANTRAN, INC., to conduct medical examinations, drug and alcohol screening tests from time to time, prior to and during employment as a condition of initial and continued employment. I also consent to searches of my person and belongings and property on Company property, upon request, as a further condition of employment. As a condition of employment, I understand that I may be required to pass a physical examination. I understand that a urine, breath, blood and/or saliva screening test to determine the presence of certain drugs and/or alcohol may be included in that physical examination. Further, during my employment, if hired, I may be requested to undergo the same screening tests and searches of my person and belongings from time to time. As an applicant, I understand that the presence of alcohol and/or drugs will disqualify me from further consideration for employment. If employed, I understand that the presence of alcohol and/or drugs in my possession or in my system while on the job will be cause for immediate termination of employment. I voluntarily consent to all such examinations, tests, searches, and release JANTRAN, INC., its officers, employees, and agent from any claims arising from (and any information obtained from) such examinations, tests or the information obtained therefrom.

Your signature will be used here if accepted.

(READ THE FOLLOWING CAREFULLY BEFORE SIGNING)

I certify that the answers supplied by me on this application are true and complete, without any material omissions, I understand that any false statements or material omissions in this application will be grounds for cancellation of the application and/or dismissal from the Company’s service if I have been employed. I understand that if employed, my employment will be for an indefinite period of time, and that I may terminate my employment at any time for any reason, and that the Company may do likewise; I further understand that no representative of the Company has authority to enter into any agreement to the contrary, unless such agreement is in writing and signed by the President of the Company. This is to inform you that an investigation may be made whereby information is obtained through personal interviews with your neighbors, friends, and others with whom you are acquainted, and that such inquiry may include information as to your character, general reputation, personal characteristics or mode of living, which will be used for employment purposes. You have the right to make a written request within a reasonable period of time for a disclosure concerning the nature and scope of this investigation. I authorize the Company to investigate the information contained in this application; I further authorize the former employers listed above to give to you any and all information concerning my previous employment, and I release all parties from liability as a result of such disclosures. I agree, if employed and an injury or illness occurs while working, to provide the Company access to all medical records related to the diagnosis and treatment of the injury or illness. I understand I may be required to take a qualification test, based on the requirements of the position, and hold harmless the Company for any injury incurred during such test. I have read and signed the applicant drug and alcohol screen and search authorization form. If employed, I agree to allow the company to deduct from my wages any monies owed to the Company for tools, equipment, uniforms and/or wage advances. Should I be hired, I understand that if I quit or I am terminated from my job with JANTRAN, INC. for any reason within 90 days of my hire date, I will be responsible for the entire cost of the pre-employment physical and drug screen. I authorize JANTRAN, INC., to deduct the cost of the pre-employment physical and drug screen through payroll deduction of my payroll check. I understand that should I leave the vessel to which I am assigned for any personal reason other than those covered by JANTRAN, INC., policy, I will assume financial responsibility for my travel. I understand that this application will be active for only 30 days from the date below. After 30 days, I understand I must personally come in and renew my application in order for it to be considered.

Application for Employment

APPLICATION IS VOID AFTER 30 DAYS

The following information is requested in order to help us make the best possible placement with the Company. All portions of this application pertaining to you must be completed, AND THE APPLICATION MUST BE SIGNED. We appreciate the time you spend filling out this application. The Company does not discriminate on the basis of age, race, religion, color, sex, national origin or physical/mental handicap.

NOTICE

If you have participated in any illegal drug use in the past thirty (30) days, DO NOT fill out this application. Please understand that you will be REQUIRED to complete a physical and drug screen on the same day as your interview with JANTRAN, Inc. should an employement offer be made to you. If you are given a physical and drug screen and do not pass the drug screening, you will be responsible for the entire cost of the phyiscal drug screen.

DRESS CODE

At all times on JANTRAN, Inc. property, all personnel must have on long pants and tucked-in shirts. There are no exceptions!!! If you are called in for an interview, you must have on long pants and your shirt must be tucked-in. You are not allowed access to the facility if you do not meet this criterion.

APPLICANT DRUG & ALCOHOL SCREEN AND SEARCH AUTHORIZATION

I authorize JANTRAN. INC., to conduct medical examinations, drug and alcohol screening tests from time to time, prior to and during employment as a condition of initial and continued employment. I also consent to searches of my person and belongings and propert on Company property, upon request, as a further condition of employment.
As a condition of employment, I understand that I may be required to pass a physical examination. I understand that a urine, breath, blood and/or saliva screening test to determine the presence of certain drugs and/or alcohol may be included in that physical examination. Further, during my employment, if hired, I may be requested to undergo the same screening tests and searches of my person and belongings from time to time.
As an applicant, I understand that the presence of alcohol and/or drugs will disqualify me from further consideration for employment. If employed, I understand that the presence of alcohol and/or drugs in my possession or in my system while on the job will be caused for immediate termination of employment.
I voluntarily consent to all such examinations, test, searches, and release JANTAN, INC., its officers, employees, and agent from any claims arising from (and any information obtained from) such examinations, tests or the information obtained therefrom.

JANTRAN

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APPLICANT DRUG & ALCOHOL SCREEN AND SEARCH AUTHORIZATION FORM