45 DAY - Milwaukee
COMMUNITY DEVELOPMENT GRANTS ADMINISTRATION
YEAR 2021
45 DAY
VERIFICATION OF EMPLOYMENT
CDGA-Funded Agency __________________________________
Activity________________________________________________
Employee's Name Original Date of Hire_______
Employee Position____________________________________________
Name of Employer
Address:
City: State Zip
Telephone Number -
1. Hours per week at hire
2. Average hours per week since hire
3. Current rate of pay
4. Is person still working? Yes _____ No ______
5. If no longer working, give last day of employment
6. Is person receiving health benefits? Yes No
7. Reason for Leaving
Name of Authorized Company Representative (Print)
_________________________________________________________ Date___________
Signature of Authorized Company Representative (Title)
_________________________________________________________ Date:___________
Project Director’s Signature (CDGA - Funded Agency)
By signing above, the funded agency and the business owner certify that the above information is true and correct and that he/she understands that the information listed on the form may be subject to verification by the City and the U.S. Dept. Of Housing and Urban Development.
Revised 08/11
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