DATE:___________
EMPLOYMENT VERIFICATION FORM
Date:___________
|employer: | |property: |
|Address: | |Address: |
|City, State, Zip | |City, State, Zip |
|Contact: | |contact: |
|tel: |fax: | |tel: |fax: |
The individual named directly below is an applicant for one of our programs. Please fill in the following information and return it to [enter your organization and fax number here]. Your prompt response will enable us to complete the application process.
Printed name of employee:__________________________________ additional info: __________________________________
THE FOLLOWING TO BE COMPLETED BY EMPLOYER
(Please provide information for all fields)
Employee’s Job Title: Presently Employed: Yes No
Hire Date: Last Day of Employment:
Current Wage/Salary:$ (circle one) hourly weekly bi-weekly semi-monthly monthly yearly other
Current Salary Effective Date:
Average # of regular hours per week:
List any anticipated change in the employee’s rate of pay within the next 12 months:
Effective date
Overtime Rate: $ per hour Average # of overtime hours per week:
EMPLOYER AUTHORIZED REPRESENTATIVE
I certify that the above information is true and correct to the best of my knowledge.
|signature/title | | | |date |
| | | | | |
|printed name | | | |telephone |
| | | | |FAX |
EMPLOYEE AUTHORIZATION FOR RELEASE OF INFORMATION
By my signature below, I authorize _______________________________________________________ to release any information requested regarding my employment to ______________________________________________.
Signed:_________________________________________________________________
Print name:______________________________________________________________
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