offshore international marine personnel services, inc. employment

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OFFSHORE INTERNATIONALMARINE PERSONNEL SERVICES, INC.

3802 W. Navy BlvdPensacola, FL 32507

Telephone: (850) 455-2995Telefax: (850) 455-3033www.offshore-int.com

EMPLOYMENT APPLICATION

Position Applying For_________________________________________________________________

Name: First________________________ Last_______________________ SS# _____-_____-______

Address __________________________________ City/State__________________ Zip __________

Phone: Home _ (____) _______________________ Cell_ (____) ____________________________

Other _ (_____) _________________________ Email Address _______________________________

Emergency Contact Person:

Name _________________________________________ Relationship _________________________

Address_______________________________________ Phone _ (____) ________________________

You could be asked to drive a company vehicle. If so, do you have a valid Driver’s License? Yes___ No___

Education:

High School Graduate: Yes___ No___ College____________________________________________

Coast Guard Licenses or Endorsements__________________________________________________

Special TrainingNOTE: WHEN FAXING OR MAILING BACK THIS APPLICATION, PLEASE SEND A COPY OF YOUR ID,MERCHANT MARINERS DOCUMENT AND ANY COAST GUARD LICENSES.

Do Not Write In This Space–For Office Use Only

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WORK HISTORY;

1. Company name_____________________________________Phone____________________

Address____________________________________Supervisor_______________________

From____________to_____________Salary_______________Position_________________

Responsibilities______________________________________________________________

Reason for leaving____________________________________________________________
















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WORK HISTORY











I hereby certify that the questions on this application have been answered truthfully, and thatmisrepresentation on my part will cancel this application and may result in separation of employmentby the employer.

_____________________________________________Signature

_____________________________________________Date

RELEASE OF INFORMATION/BACKGROUND INVESTIGATION

I, _______________________________________, do hereby give Offshore International MarinePersonnel Services, Inc., permission to contact all of my past and present employers, and to conducta background investigation as deemed necessary. I further hold Offshore International MarinePersonnel Services, Inc., free of any liabilities that may result from such an investigation. Iunderstand that this information will be presented to any and all prospective employers.

__________________________________________Signature

___________________________________________Date

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NOTICE TO APPLICANTS/EMPLOYEESREGARDING CONSUMER REPORTS

A consumer report Containing information concerning your employment history, criminalrecords, and motor vehicle records may be obtained in connection with your application forand/or continued employment with the company. A consumer report containing injury and illnessrecords and medical information may be obtained after a tentative offer of employment has beenmade.

Before any adverse action is taken, based in whole or in part on the information contained in theconsumer report, you will be provided a copy of the report, the name, address and telephonenumber of the reporting agency, a summary of your rights under the fair credit reporting act, aswell as additional information on your rights under the law.

* * * * * * * * * * * *

CONSENT TO OBTAINING CONSUMER REPORTS

READ CAREFULLY BEFORE SIGNING

1) I HAVE READ THE ATTACHED “NOTICE TO APPLICATION/EMPLOYEES REGARDING CONSUMER REPORTS” AND HEREBY AUTHORIZE THE COMPANY TO OBTAIN CONSUMER REPORTS AS DESCRIBED

__________________________PRINT YOUR NAME

__________________________SIGNATURE

__________________________DATE

MIBS FORM 1 Version 1.2

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PRIVATE EMPLOYMENT SERVICES CONTRACT

1. This contract is entered into by and between ___________________________________Hereinafter referred to as the “Applicant” and OFFSHORE INTERNATIONAL MARINE PERSONNEL SERVICES, INC. hereinafter referred to as the “EmploymentService”. Acceptance means agreement by applicant with employer to begin work.

2. Should applicant accept employment with an employer to which the employment servicehas referred him/her within one year from the date of this contract, the applicant agreesto pay a fee for professional services rendered in accordance with the schedule containedin paragraph #4. This contract can be terminated by either party at any time by writtennotice, but not to the detriment of any legal rights or obligations incurred prior to suchtermination.

3. Applicant hereby agrees to execute a payroll check mailing agreement and a limitedpower of attorney authorizing the employment service to receive applicant’s payroll checks, pay to itself the applicable placement fee and remit the remainder of wages toapplicant as spelled out in the limited power of attorney.

4. The professional service placement fee shall be based on the applicant’s projected daily wage rate, multiplied times fourteen (14) days.

5. Upon acceptance of a job, the employment service shall prepare an invoice which statesthe actual placement fee and place the invoice to the applicant’s file. The placement fee shall be paid in strict accordance with terms of the limited power of attorney alluded toabove and all files concerning the placement fee, limited power of attorney, and mailingagreement shall be maintained in the applicant’s file for a period of five (5) years after the aforementioned power of attorney expires.

6. The estimates of applicant’s daily wage rate found herein are for the purpose ofcomputing service charge and in no way guarantees the procured employment for a year.The fee is earned by the employment service when applicant accepts employment and ispayable as follows:

No down payment is required! Payments will be 20% of gross pay of eachpayroll check until fee has been paid in its entirety.

*********************************GUARANTEE********************************

When procured employment is terminated for any reason whatsoever within ninety (90)consecutive calendar days following the date employment begins, the fee charge the applicantshall not exceed twenty percent of the gross earnings of the applicant. Refunds due here undershall be made promptly by the employment service upon proper verification of earnings.

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When such payments shall be made not later than fourteen (14) days from date verification inwriting is received. The applicant shall be responsible for obtaining verification of earningsfrom the employer.

Where an employed applicant accepts employment but fails to report to work on the new job andremains with his/her present employer, the fee charged to such applicant shall not exceed twentypercent (20%) of the fee for permanent position.

******************************************************************************

7. Applicant hereby stipulates and agrees to pay a penalty of twenty-five percent (25%) asattorney fees, plus court costs, on the earned fee due the employment service should itbecome necessary for the service to obtain counsel, a collection service, or resort to courtaction to collect same.

8. It is understood that if any section of this contract is in conflict with Louisiana PrivateEmployment Service Law, or the rules and regulations established thereunder, then theprovisions of law, rule and regulations shall govern. The declaration that any section ofthis contract conflict with the provision of law shall not render the remainder of thiscontract null, and to that end, the sections of this contract are declared severable.

OFFSHORE INTERNATIONAL MARINE PERSONNEL SERVICES, INC., agrees that it willnot under any interpretation of this contract make more than one service charge for any oneplacement. The parties hereto acknowledge receipt of a copy of this contract; they have read andunderstand all provisions thereof and agree to abide by its terms and conditions.

_________________________________ ________________________________SIGNATURE OF APPLICANT DATE

____________________________SOCIAL SECURITY NUMBER

____________________________OFFHSORE INTERNATIONALMARINE PERSONNEL SERVICES, INC.

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NOTE: PAYROLL DEPARTMENT

Re: Check Mailing Agreement

I HEREBY AUTHORIZE __________________________________, to (check one below)

_____ Mail my paychecks to me at the below-listed service.

_____ Direct deposit my paychecks into the applicants escrow checking accountof the below-listed service.

OFFSHORE INTERNATIONAL MARINE PERSONNEL SERVICE, INC.

3802 W. Navy Blvd.

Pensacola, Fl. 32507

850-455-2995

____________________________________________________Signature of Applicant

____________________________________________________PRINT NAME

____________________________________________S.S. NUMBER

____________________________________________Permanent Address

____________________________________________City, State, Zip

____________________________________________Home Phone Number

Before me, the undersigned authority on this day personally appeared_______________________________ known to me to be the person whose name issubscribed to the foregoing instrument.

Given under my hand and seal this

________ day of _________________, 201___

_________________________________________

Notary Public in and for ________________________, _______City State

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LIMITED POWER OF ATTORNEY

TO: OFFSHORE INTERNATIONAL MARINE PERSONNEL, INC.

KNOW ALL BY THESE PRESENTS:

THAT I,(applicant’s name and SSN#):___________________________________________________(Permanent mailing address):____________________________________________________(City, state and zip code):_______________________________________________________(Home phone number):_________________________________________________________

Desiring to execute a LIMITED POWER OF ATTORNEY, do hereby make, name, constitute and appoint OFFSHOREINTERNATIONAL MARINE PERSONNEL SERVICES, INC./ THOMAS F. BREWER, my true and lawful agent andattorney in fact for me and in my name, place and stead to perform the following matters:

Upon receipt of my payroll check from my employer, you are to endorse and IMMEDIATELY deposit such check intothe “Applicants’ Escrow Account” of OFFSHORE INTERNATIONAL MARINE PERSONNEL SERVICES, INC.,which escrow account is to be used exclusively for the receipt and disbursement of applicants’ funds.

You are authorized to issue checks from such account on my behalf for the following purposes:

1. To OFFSHORE INTERNATIONAL MARINE PERSONNEL SERVICES, INC., in accordance with termsof my applicant contract for payment of the authorized placement fee.

2. To myself for all amounts of wages remaining after the placement fee has been paid. Checks issued to meshall be remitted in one of the manners listed below:

CHECK ONE:

( ) Hold escrow check and all employer check stubs at OFFSHORE INTERNATIONAL MARINEPERSONNEL SERVICES, INC., until I pick them up, or until I notify you to mail them to me.

( ) Mail all escrow checks at the time of issue, along with all employer check stubs to me at theaddress listed above.

Witnesses: ___________________________________

___________________________________ _______________________________Applicants’ Signature

BEFORE ME, the undersigned authority, and in the presence of competent witnesses listed above, on this daypersonally appeared the individual know by me to be the person whose name is subscribed to this instrument, andacknowledged to me that he executed this Power of Attorney for the purposes and considerations containedherein.

Given under my hand an sealThis_____day of_______, 20___

________________________________

NOTARY PUBLIC IN AND FOR ______________________, ____________________(Parish or County) (State)

offshore international marine personnel services, inc. employment

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