PHIL GUILBEAU OFFSHORE, Inc

17918 Hwy. 3235
Galliano, LA 70357

Phone: (985) 632-8669
Fax: (985) 632-8769

Required fields are noted with a (*).

Full Name: * SSN:

Present Address: * City/State: *

Home Phone: * Cell Phone:

Are you over the age of 18? Yes No Date of Birth: *

Height: Weight: Position Applied for:

Date you can start: Salary Desired:

Have you ever been convicted of a crime except a minor traffic violation? Yes No

Are you taking any prescription or over the counter medications? Yes No

If yes, what type:

Have you ever had an on the job injury? Yes No

If yes, please explain in detail:

Total years of education:
Please list at least (4) of your last employers and dates employed, complete with a phone number and/or location of their home office.
1.
2.
3.
4.
Are you Drug Free at this time? Yes No
Will you pass a urinalysis test? Yes No-
Direct Deposit Only. You must have a checking or savings account with your name on the account. Do you have an account open? Yes No
Electronic Signature (full name): * Date: