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Get ACI Form D17 1998

Make photocopies of this form as necessary. This form can be used in lieu of Forms D5 and D16. SECTION A - to be completed by the applicant Name Social Security No. Address City State Zip Home G Work G Phone Client or Owner of construction project Construction period From month year Project Location Project Type G Residential to Total Net of months City / State G Commercial G Industrial G Paving G Other Please describe I authorize those whom I have given as references to furnish to the American Concrete Institute or its agents information concerning my work experience and other background relevant to the stated requirements of the American Concrete Institute certification programs. FORM D17 Client Affidavit for self-employed examinees Concrete Flatwork Finisher MARCH 1998 INSTRUCTIONS The applicant must complete both Sections A and B of this form and then forward the form to the respondent who is to use Section C to verify the statements made in Section B. I agree to release and hold harmless any individual company or institution including the American Concrete Institute and any persons connected therewith from liability imposed by law in furnishing such information* I understand that untruths or misrepresentation contained herein constitute grounds for denial of certification* Signature of Applicant Date Print Name continued To the respondent Please examine all of the information provided by the applicant in Section B. You are being asked to verify work experience in order for this applicant to meet qualifications for certification as an ACI Concrete Flatwork Finisher. Please note that the disclaimer signed by the applicant in Section B releases you from civil liability in regard to statements provided to the best of your knowledge about the applicant and establishes that the applicant is freely requesting that you provide this information* The information provided in Section B is G Correct as stated G Correct as modified Take note of stated dates and time periods job responsibilities etc* and correct any and all inconsistencies and ambiguities by writing in corrections in Section B. In the time period listed in section B 2 I would characterize the applicant s job performance as G Satisfactory NOTE If unsatisfactory is checked explain reasons in detail below. Comments I have honestly evaluated the information being submitted on this form by the applicant. I have supplied whatever modifications may have been necessary to make all statements here-in conform to the truth to the best of my knowledge. I submit this form in the belief that it contains no misrepresentations whatsoever. Signature of Respondent Title Employer/Company Telephone. I agree to release and hold harmless any individual company or institution including the American Concrete Institute and any persons connected therewith from liability imposed by law in furnishing such information* I understand that untruths or misrepresentation contained herein constitute grounds for denial of certification* Signature of Applicant Date Print Name continued To the respondent Please examine all of the information provided by the applicant in Section B. You are being asked to verify work experience in order for this applicant to meet qualifications for certification as an ACI Concrete Flatwork Finisher.

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