Experience Verification Form
Applicant Name: _____________________________________________________________________
Business where Applicant was employed: _________________________________________________
Please print your name and the name of the company for which you worked and give this form to EACH
employer that you have worked for during the timeframe you are claiming as qualifying experience.
Employer Representative Instructions
The above Applicant has applied to become a Registered Construction Superintendent with the New
York City Department of Buildings. The Applicant indicated in his/her application that he/she gained
qualifying experience while working for the above business/firm.
Please read and follow these directions before filling out the form:
All sections of this verification form must be completed by a person authorized to by the business to
verify employee titles, duties and responsibilities.
An Employer Representative and NOT THE APPLICANT must complete all portions of this
verification form. It must be signed and notarized.
Answer every question or indicate ‘N/A’ (not applicable) when the question does not apply to you.
Once completed, please give the ORIGINAL notarized verification form(s) to the Applicant.
You may include additional information in the Comment Section or you may attach additional pages if
YOUR FAILURE TO RESPOND MAY RESULT IN THE APPLICANT’S DISQUALIFICATION
FOR THIS REGISTRATION.
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