Fillable Experience Verification Form (Page 3 of 3) in pdf

Experience Verification Form Page 3

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Construction Superintendent

Experience Verification Form

4. Are you aware of any acts or omissions by the Applicant that may reflect on his/her moral character?

Yes

COMMENTS:

I, the person signing below, have voluntarily provided the attached information on the verification form regarding this

Applicant. I attest and affirm to the truthfulness of my statements and fully understand that any false statement or any material

omission made in connection with this document is sufficient cause for The City of New York to deny the registration being

sought by the applicant. I also understand and agree that that any false statement or any material omission made in connection

with this document is sufficient cause for the City Of New York to invalidate, rescind or revoke any and all licenses and/or

registrations that were issued to me under the jurisdiction of the NYC Department of Buildings. In addition, I understand that

any such false submission may subject me to criminal charges, including, but not limited to, New York State Penal Law

sections 175.35 (offering a false statement for filing) and 240.40 (sworn false statement) and/or title 18 U.S.C section 1001 (false

or fraudulent statement), which may result in imprisonment, a fine, or both.

Print your name: _________________________________________

Sign your name: _________________________________________

Date: _______________

STATE OF ____________________)

COUNTY OF __________________) SS:

On the ___________ day of ______________________________ in the year _______________, the undersigned,

_______________________________________________, personally known to me or proved to me on the basis

of satisfactory evidence, personally appeared before me and subscribed his/her name to the above Verification

and, after being duly sworn upon his oath, says that the facts alleged in the foregoing affidavit are true.

________________________________________________

(Notary Public)

Applicant’s Name ___________________________________

Employer Rep. Initial here ________

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Experience Verification Form Page 3

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