Social Security:*
Home Phone:
Cell Phone:
Merchant Mariners Credential Number:
Twic Number:
Drivers License Number:
Drivers license state:
Are you over the age 18 years old and can you provide required proof of your eligibility to work?*
Miller's Launch, Inc is an equal opportunity/affirmative action employer. Miller's Launch, Inc policy is to abide by all federal, state and local laws prohibiting discrimination in employment because of race, color, gender, religion, national origin, age, sexual orientation, disability(where the person is able to perform the essential functions of the position), veteran status, citizenship status or other prohibited reasons.
Acceptable salary range:
Date you could start work:
Days available to work:
List below your three most recent employers. Give employment information as complete as possible starting with your present or most recent employer. List any unemployed or self-employed periods under your company name. If you were employed under another name, please enter that information under the company name.
Start-Finish Date:
Start-Finish Date :
Start -Finish Date
HS Graduated:
HS Graduation Date:
College Graduated:
College Graduation Date:
Technical school Graduted:
Technical School Graduation Date:

Essential Duties of the Position

Is there any reason you can not perform the essential duties of the position, which include but are not limited to the following, with or without a reasonable accommodation:

Lifting / Pulling 70 pounds:
Standing, walking for 8 hours:
Climbing ladders:
Throwing a 25lb line:
Working in close quarters:


´╗┐Please list the name, address and telephone number of three business/academic references, other than relatives.

Reference #1 Name:
Reference #2 Name:
Reference #3 Name:

Acceptable file formats (jpg, jpeg, png, gif, doc, docx, xls, xlsx, pdf)

MM Credential:
Drivers License:

Please read this statement carefully before signing this application

I hereby certify that the Information contained In this application Is correct to the best of my knowledge and understand that, if I am employed, any misrepresentation or omission of material facts on this application, regardless of when discovered, Is sufficient cause for dismissal. I understand that my employment and compensation can be terminated at any time without cause and with or without notice at any time, at the option of Miller's Launch, Inc. or myself. I understand that no one has the authority to promise permanent
employment or employment for a definite period of time.

The company, In considering my application for employment, may verify the information set forth in this application. I authorize all persons, schools, companies, corporations, and doctors to supply any information concerning my application. Provided state law permits, I further agree to submit to alcohol and drug screening tests and polygraph examinations, if requested of me at any time prior to, or during my employment.

Applicant Name:
Applicant E-mail: