Membership Application

General Information

Social Security Number*

show Social Security Number

Mariner Reference Number (MRN)*

Have you been a member of AMO previously?*

Yes

No

I'm applying for:

Deep Sea

Great Lakes

Inland Waters

Name*

First Middle Last

Permanent Address*

Street Address Address Line 2 City State ZIP Code

Is your Permanent address the same as your Mailing address?*

Yes

No

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Ethnicity*

White

Black

Hispanic

American Indian or Alaskan White

Other

Unknown

Gender*

Male

Female

Unspecified or another gender identity

Email Address*

Mobile Phone*

Alternate Phone

Employment for the Past Year

Company / Employer

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Job Title

Length of Employment

Do you need to enter another employer?

Yes

No

Additional Employment

Please enter all additional employment here. Use the above questions as a guide for what information to include.

Character References

First Reference

Name*

Phone*

Occupation*

Second Reference

Name*

Phone*

Occupation*

Training Certificates

Military Sealift Command

Helicopter Landing

Helicopter Firefighting

Damage Control

SAAM

Ship Reaction Force

Security Watchstander (Basic)

Security Watchstander (Advanced)

Engineering

High Voltage

Refrigerant Recovery

Engineroom Resource Management

Gas Turbine

Deck

Bridge Resource Management

Designated Care Provider

Medical PIC

ECDIS

Tankerman PIC (DL)

DP Training

NI DP Operator

Pilotage

General Training

Vessel Security Training

NS5

Other Training (Explain)

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AMERICAN MARITIME OFFICERS VACATION PLAN

P.O. Box 35, Dania Beach, FL 33004 Tel: (954) 920-4247 (800) 348-6515 Ext. 15 Fax: (954) 926-7274 www.amoplans.com Email: amovacation@amoplans.com

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APPLICANT’S DEDUCTION AUTHORIZATION FOR INITIATION FEES, DUES, & FINES TO THE AMERICAN MARITIME OFFICERS

While Dues/Initiation fees and fine(s) to the American Maritime Officers are not taxable for Federal income tax purposes; they may be tax deductible under other provisions of the Internal Revenue Code.

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Name

I_____________________________________________, hereby (Please Print) authorize and direct American Maritime Officers Vacation Plan to deduct from vacation benefits due to me, monies due and payable by me as initiation fees, dues and fines to American Maritime Officers. I authorize said deduction to be made from any vacation payment made to me and to be forwarded by the American Maritime Officers Vacation Plan to the American Maritime Officers at 601 S. Federal Hwy, Dania Beach, Florida, 33004. ¹ This authorization is unconditional and, binding upon me, and may not be amended, rescinded, or terminated without the authorization of the Secretary/Treasurer of American Maritime Officers.

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Applicant Signature

Last 4 of SSN

Date

Upload Documents

All images should be in color. All documents are securely sent directly to DropBox where they are encrypted so your data is kept safe.

Please upload all pages of your Merchant Mariner Credential, including the last page with the U.S. Coast Guard signature*

Drop files here or