Reliant Maritime Solutions, LLC

In connection with employment at RMS (hereafter “Company”), may request a medical inquiry and/or examination for purposes of establishing and verifying the performance of essential job-related functions with and without reasonable accommodation. I authorize and request all healthcare providers or hospitals to release said information for verification of a medical inquiry, if required, to the Company, its designated representatives, or its healthcare provider. I also understand and agree that I may be required to take a fitness for duty exam when there is a need to determine whether I am still able to perform the essential functions or the job in a safe and complaint manner. I hereby hold harmless the Company, its officers, directors, employers, agents and assigns, for my death, any personal injury or illness resulting from, arising out of, or incurred during such test, without regard to the causes thereof of the Company’s negligence, whether sole, joint, concurrent,active, or passive. I authorize a photocopy of facsimile of the Medical Information Release to be considered as effective and valid as the original. All results will be proprietary, will be kept confidential, and will not be provided to and parties other than the Company or its legal representatives, unless required to do so by court order or subpoena. I voluntarily waive all recourse against and hereby release the requested parties from liability for complying with this Medical Information Release. The Company’s retrieval and usage of this information will comply with applicable laws, rules, and regulations. The Company is an Equal Opportunity Employer and does not discriminate based upon race, color, gender, national origin, religion, age or disability. I further understand that the above information has been explained to me, and I fully understand its contents and applications.

By checking the box, I acknowledge that I have read and understand all of the above statements.

I certify that all the information that I have provided is true and complete to the best of my knowledge. I understand that false statements on this application are sufficient cause for denial of employment or, if employed reason enough for dismissal without regard to the length of my employment. If hired, I understand and agree that my employment is for no definite period of time and may be terminated at any time without prior notice. My employment with Reliant Maritime Solutions shall be “at will” and nothing herein shall institute any contract of employment between the employer and applicant. I am aware that I will be given a comprehensive physical exam which includes a drug and alcohol screen administered by a company physician prior to my employment and that I will be subject to drug and alcohol testing as required by Company policy and/or U.S. Coast Guard regulations. NOTICE TO APPLICANT REGARDING CONSUMER REPORTS and BACKGROUND CHECKS – A consumer report, investigative consumer report and/or background check including information concerning your character, employment history, general reputation, personal characteristics, police record, education, qualifications, motor vehicle record, mode of living and/or credit and indebtedness may be obtained in connection with your application for and continued employment with the company. A consumer report containing medical information, and injury or illness records may be obtained after a tentative offer of employment has been made. Upon five (5) days of a written request of RMS, the scope of the consumer report and background check may be disclosed to you. Before any adverse action is taken based in whole or in part of the information contained in these reports and checks, you will be provided copies of the reports including contact information of the reporting agencies, a summary of your rights under the law. CONSENT TO OBTAINING CONSUMER REPORTS and/or BACKGROUND CHECKS – I HAVE READ THE “NOTICE TO APPLICANT REGARDING CONSUMER REPORTS AND BACKGROUND CHECKS” AND HEREBY AUTHORIZE THE COMPANY TO OBTAIN CONSUMER REPORTS INVESTIGATIVE REPORTS AND/OR BACKGROUND CHECKS AS DESCRIBED. I UNDERSTAND THAT I HAVE THE RIGHT TO MAKE A WRITTEN REQUEST TO RECEIVE ADDITIONAL INFORMATION ABOUT ANY INVESTIGATION OR REPORTS THAT ARE MADE INCLUDING THE NAME, ADDRESS, AND TELEPHONE NUMBER OF THE REPORTING AGENCY. I HEREBY AUTHORIZE ANY PRESENT OR FORMER EMPLOYER, CONSUMER REPORTING AGENCIES, EDUCATIONAL INSTITUTIONS, CRIMINAL JUSTICE AGENCIES, DEPARTMENTS OF MOTOR VEHICLES, PUBLIC AGENCIES, FINANCIAL INSTITUTIONS, AND OTHER PERSONS OR AGENCIES TO SUBMIT ANY INFORMATION AND/OR THEIR OPINIONS ON ME. I HOLD SAID PERSONS AND/OR ORGANIZATIONS WITHOUT LIABILITY FOR STATEMENTS AND/OR OPINIONS MADE REGARDING MY CHARACTER EXPERIENCE OR QUALIFICATIONS.

By checking the box, I acknowledge that I have read and understand all of the above statements.

I understand and agree that prior to employment and/or during the course of employment, I may be required to submit to tests to determine alcohol or drug use (including but not limited to breathalyzer, urinalysis, hair tests, and/or blood tests), and I hereby release from all liability all clinics, doctors, nurses or contractors who conduct such tests. consent to the taking of such tests as directed by Reliant Maritime Solutions and further consent that the results of any such tests may form the basis for withdrawal of any offer or for my termination if hired. I authorize a photocopy of facsimile of this release to be considered as effective and valid as the original. All results will be proprietary and will be kept confidential and will not be provided to any other parties other than the company, our legal representatives, government agencies, or other perspective employers as required by law, court order, or subpoena. I hereby understand and agree that If I (1) fail a chemical test for controlled substances, (2) fail a breath alcohol test, or (3) refuse to participate in a company conducted pre-employment, random, reasonable cause, or post accident test. I will be denied employment as a crew member, and be subjected to suspension and revocation proceedings according to application United States Coast Guard regulations. I further understand and agree to hold harmless RMS ,our employees, agents, and assigns from any action taken against my License, Certificate or Registry, or Merchant Mariner’s Document as a result of my refusal or positive test results. RMS retrieval and usage of this information will comply with applicable laws, rules, and regulations. RMS is an Equal Opportunity Employer and does not discriminate based upon race, color, gender, national origin, religion, age, or disability.

By checking the box, I acknowledge that I have read and understand all of the above statements.