INITIAL EMPLOYMENT VERIFICATION



EMPLOYMENT VERIFICATIONCONTRACTOR CODE-6BRToday’s Date: FORMTEXT ???????????????????????????????????????Verification for: FORMCHECKBOX Initial Placement* FORMCHECKBOX 90-Days employment retentionParticipant Name: FORMTEXT ????????????????????????????? FORMTEXT ?????????????????????????????? FORMTEXT ???- FORMTEXT ??- FORMTEXT ????LastFirst NameSocial Security No. Job Title: FORMTEXT ?????????????????????????????????????????????????????????????????????????????????????????Employer Name: FORMTEXT ????????????????????????????????????????????????????????????????????????????Employer Address: FORMTEXT ?????????????????????????????????????????????????City/Zip: FORMTEXT ??????????????????????????????Employer Contact: FORMTEXT ?????????????????????????????????????????????????Phone: FORMTEXT ??????????????????????????????Please check and complete one of the following:Verification Method4558030190500016383001905000 FORMCHECKBOX EMPLOYER To be filled by the employer I certify that the above named individual has worked FORMCHECKBOX 1 day FORMCHECKBOX 90 days from the date of hire (please check mark the applicable box) Date of Hire (or re-hire)or Date this Job Started : FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ????? Hrs worked / week: FORMTEXT ???????????????????????????????????Hourly Wage: $ FORMTEXT ????????????Health Insurance is (or will be) Available FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????????????????????????????????????????????????? FORMTEXT ???????????????????????????????Employer Signature and printed Name DateOR FORMCHECKBOX WAGE STUB Please make sure that a copy of the wage stub(s) is attached.OR FORMCHECKBOX Spoke with ___________________________________ at _____________________________ .printed name of employertelephone number_______________________________ still works _______ hours a week and earning $________ an hour. client name ______________________________ ___________________________________ _________________ TRAC staff signatureTRAC staff printed name Date ................
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