Form D5 PDF Details

The D5 form serves as a crucial document for individuals seeking certification as a Specialty Commercial / Industrial Concrete Flatwork Finisher, a designation that acknowledges proficiency in specific concrete finishing techniques and knowledge. Initiated in November 2007, this form functions as the Examinee Application Form, meticulously designed to collect detailed information from applicants about their concrete finishing work experience. It is divided into three sections; Section A requires the applicant to provide personal details along with preferred contact information and employment data. Moving on to Section B, it delves deeper, asking for comprehensive work experience from the applicant, including employer information, job title or description, the timeframe of employment, and a breakdown of tasks related to concrete finishing. Additionally, applicants must disclose the percentage of time dedicated to various concrete finishing tasks, ensuring full transparency about the scope of their responsibilities. The form also includes a crucial element where applicants authorize the verification of their work experience and agree to a liability release, setting the stage for honest and validated submissions. In Section C, designed for the respondent, usually a supervisor or employer, to complete, it calls for an examination and verification of the applicant's claims regarding work experience, with provisions for correcting any discrepancies. This process not only reinforces the credibility of the information provided but also underscores the form's role in the certification process, ensuring that only qualified individuals achieve the prestigious ACI Concrete Flatwork Finisher certification.

QuestionAnswer
Form NameForm D5
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmisrepresentations, formular d5, 2007, D5

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FORM D5 Examinee Application Form

Specialty Commercial / Industrial Concrete Flatwork Finisher

November 2007

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. See the CRAFTSMAN WORKBOOK for complete instructions. Make photocopies of this form as necessary for multiple employers.

SECTION A - to be completed by the applicant

1.

Name of Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits SSN

 

 

Address

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

Zip

 

 

Applicant Preferred Contact Phone

 

 

 

 

 

 

 

 

 

G Home

G Work

 

 

 

G Cell

 

Applicant Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION B - to be completed by the applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Employer (during time period in question)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

to

Total

 

Job title or description

 

 

 

 

 

 

 

 

 

 

 

 

month & year

 

 

month & year

 

 

Net # of months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Address

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

State

 

 

Zip

 

3.

Name of Respondent verifying work experience

 

 

 

 

Title

 

 

 

 

 

 

During this time period, the relationship of the respondent to me (applicant) was:

G Supervisor

G Employer

G Other - Please explain

4.List the percentage of time spent in concrete finishing related work:

%Commercial Flatwork Construction

%Industrial Flatwork Construction

%Application of Surface Treatments (Hardeners)

%High Tolerance (Superflat) Flatwork Construction

%Silica Fume Concrete Flatwork Construction

%TOTAL Note:100% means you worked strictly as a full-time employee (40 hours) with concrete finishing related work as your only responsibility. Less than 100% means your weekly time spent in concrete finishing related work, averaged over your period of employment, was less than 40 hours. This condition would exist if you had divided responsibility between concrete finishing and non-concrete finishing related work; OR, you worked solely on concrete finishing related work, but less than full time OR not steadily during the time period.

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. 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

SECTION C - to be completed by the respondent

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.

1.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.

2.In the time period listed in section B, #2, I would characterize the applicant's job performance as:

G Satisfactory

G Unsatisfactory

G No Opinion

NOTE: If any box other than "satisfactory" is checked, explain reasons in detail below.

3.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 herein 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

 

 

Date

 

 

 

 

 

Print Name

 

Title

 

 

 

 

 

Present Employer

 

 

Employer Telephone

Summary of Respondent's Qualifications (state your educational background, work experience, certifications and affiliations with professional organizations here):

IMPORTANT NOTE TO RESPONDENT:

The applicant should not see this form after you have completed Section C.

Return the completed form to the applicant in a sealed envelope.

November 2007

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