I certify that the facts and my answers on this questionnaire are true and complete to the best of my knowledge. I understand that any falsifications, misrepresentations or omissions will be cause for withdrawal of conditional job offer or immediate termination regardless of when or how discovered. The terms “misrepresentation” or “omission” include failure to complete this questionnaire form. It is the company policy that inadequately completing company documents may be grounds for denial of employment, withdrawal of a conditional job offer or immediate termination. Inadequate completion includes drawing a line through all “NO” responses since this indicates failure to appropriately consider the company’s request for information. Additionally, false or misleading answers may be a basis for denial of benefits under federal maritime law, denial of maintenance and/ or cure, or any otherwise applicable benefits. Providing thorough and accurate information is required.