DAKOTA COUNTY COMMUNITY SERVICES
Employment Verification
| | |Authorization |
|Employer: |I grant permission to the Employer listed to provide and verify the information requested on this form. |
|Address: |This is valid for 1 year or when I withdraw it in writing. |
| | |
| | |
| | |
|Case Name: | |
|Case #: | |
| | |
| | | | |
| |(Employee Signature) | |Date |
| | | | | |
|Dear Employer: | | | | |
|3 | | |
|The above person has stated that s/he has been previously or is currently employed by your firm. Verification of this is required. Please complete the information |
|request below. Note the above signature allowing release of this information. Thank you. |
| |
|Sincerely, |
| |
|Name Title Phone Fax |
|Employer Please Complete All Items That Apply: |
| |
|Starting Employment | |
| | |
Starting Date ________________ Rate of Pay$ ________________
Pay Periods weekly bi-weekly semi-monthly monthly
Pay Dates _____________________________
Days per Week_______________ Hours per Day ________________
Gross amount of first check _______________
Date received or to be received _______________
Tips (estimate per pay period) ________________
Verify work schedule (list time) ______ ______ ______ ______ ______ ______ _______
Mon Tues Wed Thurs Fri Sat Sun
______ ______ ______ ______ ______ ______ _______
Mon Tues Wed Thurs Fri Sat Sun
| |Type of position: | Permanent |
| | | Temporary If temporary, for how long? | | |
| Job Title: _______________________________________________________ |
| Is insurance available? YES NO Health Dental Vision Cobra |
| |If no, what date can employee enroll? | | |
| |Name of Insurance Co/Address | |
| |Group No. | |Contact No. | |Is dependent coverage available? | |
| |Does employee currently have coverage? | YES NO |Dependents? YES NO |
| |List cost to employee for: Employee only |$ |Family |$ |Empl + 1 |$ |
| |Please complete next page. |
| Other | |
| | | | |
|Printed name of employer | |Signature of employer |
| | | |
| | | | |
|Employer title | |Date |
| | | |
Telephone Number Fax Number
This institution is an equal opportunity provider
|Please List Wages And Deductions For The Months of | |Thru | |For | |
| |(Name of Employee) |
|Date Paid |Tips |Gross Wages |Federal Taxes |
| |
|TELEPHONE NUMBER | |DATE | |
| | | | |
|FAX NUMBER | | | |
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EDAK 0058ESW
4/15/11
Section 1
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Workforce Services return to:
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______________________________________
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