Employment Application

Outfitting Specialists in Marine Accomodations

Contact Information:
QCI Marine Offshore, LLC
6754 Willowbrook Park Drive
Houston, Texas 77066
Tel: (281) 885-1300
Fax: (281) 885-1349
E-mail: info@QCImarine.com

An Equal Opportunity Employer

Date of Application:
Positions Applied For:
Name
Last:
Middle:
First:
Address
Street:
City:
State:
County/Parish:
Zip:
Telephone
Social Security
Email Address:

Type of Employment desired:	Full Time	Part Time
If you are under 18, can you furnish a work permit?	Yes	No
Have you ever been employed by QCI Marine Offshore, LLC?	Yes	No
Are you legally eligible for employment in this country?	Yes	No
(Proof of U.S. citizenship or immigration status will be required upon employment)
Are you able to meet the attendance requirements of the position?	Yes	No
Have you ever been convicted of a felony in the last seven (7) years?	Yes	No
(Such a conviction may be relevant if job related, but does not bar you from employment.)
If yes please explain:

EMPLOYMENT HISTORY

List your last two(2) employers, assignments, or volunteer activities, starting with the most recent,
including military experience.

Dates of Employment ie (xx/xx/xxxx)	From	To

Employer #1 Name:
Address:
City:
State:
Telephone: ie (xxx) xxx-xxxx
Job Title:
Supervisor:
Job Responsibilities:
Reason For Leaving:
Hourly Rate / Salary:
Start $	(select one)HourMonthYear
Finish $	(select one)HourMonthYear

Dates of Employment ie (xx/xx/xxxx)	From	To

Employer #2 Name:
Address:
City:
State:
Telephone: ie (xxx) xxx-xxxx
Job Title:
Supervisor:
Job Responsibilities:
Reason For Leaving:
Hourly Rate / Salary:
Start $	(select one) Hour MonthYear
Finish $	(select one)HourMonthYear

SKILLS and QUALIFICATIONS

Please summarize special skills and qualifications acquired from employment or other experiences
that may qualify you for work with QCI Marine Offshore, LLC.

EDUCATIONAL BACKGROUND

Name and Location	Year Completed	Did you Graduate?	Course of Study / Degree
High School	1 2 34	YesNo
College	1234	YesNo
Other

MEDICAL HISTORY

1. Do you now have, or have you ever had, any injuries or illnesses, which would hinder you from performing the activities involved in the job or occupation for which you are applying for?			YesNo
If you checked yes please explain:

2. Have you ever been hospitalized?			YesNo
If you checked yes please explain:

3. Have you ever been hurt on the job?			YesNo
If you checked yes please explain:

REFERENCES

NAME	TELEPHONE NUMBER (XXX) XXX-XXXX	# OF YEARS KNOWN
1.
2.
3.
4.

Please attach resume: