**Supplemental Experience Form**

**Maintenance Worker**

**BB ‑ 4749 - 00**

**Name of Applicant:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

To enable us to accurately evaluate your experience and training, please
complete this supplemental form and submit it with your application.

1.  Please check the type(s) of directions you worked from on previous
    jobs:

**Oral Instructions:**

> **Yes \_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_**

**Written Instructions:**

> **Yes \_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_**

**Oral or Written Instruction on Rapidly Changing Jobs:**

> **Yes \_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_**

2.  Check any of the following tools and equipments you have used:

  ----------------------------------- -----------------------------------
  **Power**                           **Hand**

  ----------------------------------- -----------------------------------

  --------- ------------------------- -------- --------------------------
            **Chain Saw**                      **Shovel**

            **Welding Equipment**              **Pick**

            **Jackhammer**                     **Tamper**

            **Airhammer**                      **Hammer**

            **Paving Breaker**                 **Saw**

            **Front-End Loader**               **Trowel**

            **1 2 Yard and Under**             **Paint Brush**

            **Mower**                          **Paint Roller**

            **DumpTruck (2 Axle)**             **Cement Mixer**

            **Drill**                          **Posthole Digger**

            **Posthole Digger**                **Screwdriver**

            **Chemical Spray Rig**             **Tape Measure**
            **Truck or Trailer                 
            Mounted**                          

            **Paint Spray Gun**                **Drill**

            **Farm-Type Tractor**              **Rake**

            **Mud Jack**                       **Wrench**

                                               **Paint Scraper**

                                               **Pliers**

                                               **Pipe Wrench**
  --------- ------------------------- -------- --------------------------

3.  Have you ever performed tool or equipment maintenance which may have
    involved keeping items clean, making simple adjustments,
    calibration, adjusting equipment to operating tolerances, etc.?

**Yes \_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_**

> Please describe and explain:
>
> Also please indicate who you were working for and give dates of
> employment. ( If more space is needed please continue on Page 4. )

4.  For each type of materials listed below, write the number of the
    statement that shows your ability level. Then give examples of work
    you performed that shows how you used your ability.

> **1 - Have used the material when working under close supervisory
> guidance.**
>
> **2 - Have used the material and planned operations on the basis of my
> own judgment and experience with occasional supervisory guidance.**
>
> **3 - Am an expert concerning the material and have been consulted by
> co-workers for advice on its use or appropriate substitute.**

  ------------------- ------------- ----------------------------------------
  **Materials**       **Statement   **Examples of Work You Performed & Where
                      Number**      & When You Performed This Work**

  **Lumber *( Example **3**         **1975-77 Carpenter - I.E. Smith Co.**
  )***                              

  **Lumber**                        

  **Concrete**                      

  **Chain-Link                      
  Fence**                           

  **Pipe**                          

  **Paints**                        

  **Weed Spray**                    

  **Rodent Poison**                 

  **Welding                         
  Materials**                       

  **Pavement Repair                 
  Materials**                       

  **Building                        
  Supplies**                        
  ------------------- ------------- ----------------------------------------

5.  Check the weights you have had to lift and carry:

> **10 lbs. \_\_\_\_\_\_\_\_\_\_ 20 lbs. \_\_\_\_\_\_\_\_\_\_ 40 lbs.
> \_\_\_\_\_\_\_\_\_\_**
>
> **50 lbs. \_\_\_\_\_\_\_\_\_\_ 100 lbs. \_\_\_\_\_\_\_\_\_\_**
>
> List some of the heavy things you have lifted and tell about your
> activities or experiences that required physical strength and
> endurance.

6\. Tell about any work you did where you had to observe safety rules to
avoid injuring yourself or co-workers (e.g., equipment operation,
materials handling, etc.)

7.  Have you had a lost-time accident in the last 5 years?

> **Yes \_\_\_\_\_\_\_\_\_\_ No \_\_\_\_\_\_\_\_\_\_**

Please state whether you were at fault and the severity. List any safety
awards.

8.  If you have been employed as a Maintenance Worker or in a closely
    related field, check the statement below that best characterizes
    your level of performance and supervision received.

> **\_\_\_\_\_\_\_\_\_\_ Able to independently decide which simple tasks
> should be done and to carry out those tasks with supervisory
> guidance.**
>
> **\_\_\_\_\_\_\_\_\_\_** **Able to perform the common tasks associated
> with Journeyman duties on own initiative subject to occasional
> inspection.**
>
> **\_\_\_\_\_\_\_\_\_\_** **Able to perform the more difficult tasks
> associated with Journeyman duties on own initiative and with very
> little supervision.**

9.  Please provide information concerning your driving record on the
    pages at the end of this supplemental form.

After completing the application and this form, look it over carefully
to make sure that both have been signed and that you have answered every
question. Be sure you have given complete information about your
experiences, including volunteer work, etc. ***[You]{.underline}
[cannot]{.underline} [be]{.underline} [given]{.underline}
[credit]{.underline} [for]{.underline} [work]{.underline}
[you]{.underline} [do]{.underline} [not]{.underline} [tell]{.underline}
[us]{.underline} [about]{.underline}!***

**STATEMENTS CONCERNING QUALIFICATIONS MAY BE VERIFIED. EXAGGERATION OR
MISSTATEMENTS MAY BE CAUSE FOR YOUR DISQUALIFICATION OR LATER REMOVAL
FROM THE SERVICE.**

**Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_**