Experience Verification Form Page 2
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3Construction Superintendent
Experience Verification Form
EMPLOYER INFORMATION
Your name: _________________________________________________________________________
Your current job title: __________________________________________________________________
Your previous job title*: ________________________________________________________________
Your current telephone number: ____________________ Email address: ________________________
Do you hold any Professional licenses, certifications, or registrations?
Yes
No
License Type & No.: _________________________
Issuing Agency: _______________________
License Type & No.: _________________________
Issuing Agency: _______________________
APPLICANT’S EMPLOYMENT INFORMATION
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Employed From _____________
To ____________
Full Time
Part Time
Applicant’s Position/Title(s): ____________________________________________________________
1. Is applicant able to read construction plans and specifications?
Yes
No
2. Did the Applicant obtain field experience as a:
a. Safety Official with this employer?
Yes
No
b. Safety Manager or Safety Engineer with this employer?
Yes
No
c. The employer was a (check one)
Government entity
Construction firm
Safety consulting firm specializing in construction or demolition
3. While at this employer OR while working with this client, did the applicant work with plans in a
relevant construction trade in furtherance of the construction, vertical or horizontal enlargement or full
demolition of a building or structure?
Yes
No
If yes to Question 3, describe the type of work done by the Applicant (continued on next page)
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Full time employment is working a minimum of 35 hours, per week. The Department will verify with the Applicant’s proof
of earnings.
*Complete this section if your title has changed within the company or you are no longer employed by this company.
Applicant’s Name ___________________________________
Employer Rep. Initial here ________
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