Application for Membership Please enable JavaScript in your browser to complete this form.Application Date *Port Office *BostonCharlestonHonoluluHoustonLos Angeles/Long BeachMiami/Port EvergladesNew York/New JerseyNorfolk, VAOaklandSeattleTampaI hereby make application for membership within the OFFSHORE MEMBERSHIP GROUP as *Licensed OfficerUnlicensed MarinerAdministrative/ShoresideName *FirstMiddleLastLast 4 SSN *Phone (mobile) *Phone (home)Email *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCENSUS DATADate of BirthGenderMaleFemaleNon-BinaryOtherPrefer Not to RespondRaceAmerican Indian/Alaska NativeAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhiteOtherPrefer Not to RespondEMERGENCY CONTACT INFOEmergency Contact NameFirstLastRelationshipEmergency Contact AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmergency Contact PhoneMARITIME EDUCATIONMaritime School AttendedCalifornia Maritime AcademyGreat Lakes River AcademyUSMMA - Kings PointMITAGS-EastMITAGS-WestMassachusetts Maritime CollegeMaine Maritime AcademyNY State Maritime CollegePiney PointUS Coast Guard AcademyTexas A&M - GalvestonOtherName of Maritime School AttendedYear GraduatedMerchant Mariner's Document/Credential No.License RatingMasterChief MateSecond MateThird MateYear IssuedPilotageYesNoEngineerSteamMotorTankerman PICYesNoEndorsementsSecurity Clearance *YesNoExpiration Date *Level *Additional Qualifications (teaching credentials, maritime field shoreside, etc.)EMPLOYMENT RECORD(Please list last employer first)(1) Dates of Employment(1) Employer Name/Address(1) Salary & Position(1) Reason for LeavingDo you have another employer to enter?YesNo(2) Dates of Employment(2) Employer Name/Address(2) Salary & Position(2) Reason for LeavingDo you have another employer to enter?YesNo(3) Dates of Employment(3) Employer Name/Address(3) Salary & Position(3) Reason for LeavingDo you have another employer to enter?YesNo(4) Dates of Employment(4) Employer Name/Address(4) Salary & Position(4) Reason for LeavingWere you, or are you now, a member or applicant of any other union(s)? *YesNoIf yes, which union:No. of years If accepted as an MM&P applicant, I agree to be governed by the MM&P International Constitution and the Work Rules and/or Shipping Rules of the membership group with which I am affiliated. I agree to pay the necessary service fees (dues/assessments/initiation) and acknowledge that if I fail to meet my financial obligations to MM&P or violate its rules or contracts, I may lose my status as an applicant and become ineligible for membership. I understand that I will not be considered for membership in any MM&P membership group until I have tendered my full initiation fee along with all required dues and assessments. If rejected by the General Executive Board or if I voluntarily leave MM&P, a prorated portion of my initiation fee may be refunded, but not the dues or the assessments paid. I pledge to carry out my duties and obligations and to uphold and advocate the objectives of MM&P and to treat all MM&P members with respect and consideration. I also hereby designate MM&P to act as my exclusive representative to bargain with my employer for wages and terms and conditions of employment. I authorize the investigation of all statements contained in this application and understand that the presentation of false or misleading information on this application may be grounds for voiding the application and/or denying an individual any privileges or membership in MM&P. I understand that it is my obligation to report to MM&P any matter which would affect or change any information contained in this application. Signed * Clear Signature Applicant for MembershipDate *Witness * Clear Signature MM&P RepresentativeDate *Witness *Printed NameSubmit