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Fillable Concrete Safety Manager Experience Verification Form - Rev. 3/14

Fillable Concrete Safety Manager Experience Verification Form - Rev. 3/14 2026

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The document is an Experience Verification Form for applicants seeking to become Registered Concrete Safety Managers in New York City. It outlines the process for applicants to provide their employment history and requires employers to verify the applicant's experience in concrete operations. The form must be completed by an authorized employer representative, signed, notarized, and submitted to the Department of Buildings. It emphasizes the importance of truthful information and the consequences of false statements.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Applicant Name and Business where the applicant was employed in the designated fields. Ensure that this information is printed clearly.
Instruct the employer representative to complete their section, including their name, job title, and contact information. This section must be filled out by an authorized individual, not an HR employee.
Fill in the employment details for the applicant, including dates of employment and whether they worked full-time or part-time. Specify the applicant's position/title(s) during their employment.
Answer questions regarding the applicant's experience in concrete operations. Indicate 'Yes' or 'No' as applicable and provide a description of their duties.
Complete the table detailing each job site where the applicant worked, including volume of concrete placed and job site address.
Add any additional comments about the applicant’s experience and moral character as required before signing and notarizing the form.

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