Storm Worker Registration Form

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Storm Worker Registration Form

Storm Worker Registration Form

If you wish to be added to the list of Maverick Storm Workers deployed in the event of a storm or other natural disaster, please fill out the below form with all of your details.

Phone Number Email Last Name First Name Company Name Street Address City Zip

CDL license? YesNo

Current medical certificate? YesNo

Clean driving record? YesNo

Will you travel for storm work? YesNo

Ability to climb poles? YesNo

Are you able to travel and be on the road for long durations? 1 week2 weeks3 weeks4+ weeks

Primary line worker classification:

Journeyman LinemanEquipment OperatorGroundmanApprenticeForemanGeneral ForemanLine SupervisorNot ApplicableOther (enter below)

Secondary line worker classification:

Journeyman LinemanEquipment OperatorGroundmanApprenticeForemanGeneral ForemanLine SupervisorNot ApplicableOther (enter below)

Damage assessor worker classification:

Lead AssessorDriver/Jr. AssessorDamage Assessor SupervisorNot ApplicableOther (enter below)

Wire Guard Worker Classification:

Wire GuardWire Guard SupervisorNot ApplicableOther (enter below)

Professional Services:

AdminProject ManagerSafetyLogisticsNot ApplicableOther (enter below)

Current Safety Certifications:

Pole Top Rescue CPR Bucket Rescue Hazardous Communication Chain Saw Safety Personal Protective Equipment First Aid Confined Space 1910.269 Electric Hazard Awareness MUTCD Traffic Control Use of Insulated Tools OSHA 30 OSHA 10 Other (enter below)

One Westinghouse Plaza, Suite D6, Boston, MA 02136

1-617-797-2074

sales@maverickcorporation.com

Maverick Corporation

Safety, Quality, Integrity, Excellence