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Blank Verification of Employment

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Lillian Awt
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6 views

Blank Verification of Employment

Uploaded by

Lillian Awt
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Employment Verification Form

To be completed with blue or black ink only. Please print legibly- no white out allowed

Dear Employer, Date: ______________________________


In order to determine the eligibility for child care/early learning services, please assist by answering the questions below.

Employee Information - to be completed in full by employer- (income information is needed for the last 4 current and consecutive weeks of pay):

DATE PAY RECEIVED GROSS EARNINGS


BEFORE ANY NUMBER OF
(LIST MOST RECENT
DEDUCTIONS HOURS NET PAY
PAY
(INCLUDES OVERTIME, SHIFT DIFFERENTIAL, TIPS, ETC.) WORKED
PERIOD FIRST)

1)
2)
3)
4)

Employee Name ________________________ Start Date: _______________________ Employee End Date: _____________________

Check Days Worked: Mon _____ Tues _____ Wed_____ Thurs _____ Fri_____ Sat_____ Sun_____

Work Schedule: From _________ am/pm To _________ am/pm OR Varied Hours: ______________

Hourly Wage: $__________ # Hours/Week: _______ #Days/Week: _____________

Paid: Weekly ____ Bi-Weekly____ Semi-Monthly____ Monthly____

Eligible for overtime? Yes____ No____ If yes, how frequent is overtime worked? ____________

Eligible for shift differential? Yes____ No____

Employer Information - to be completed in full, signed and dated by employer

Company Name: _________________________________________________________________


Street Address: __________________________________________________________________
City/State: __________________________________ Zip Code: __________________
Employer’s Telephone: ________________________

__________________________________________________ _____________________________________________
Printed Name Signature
___________________________________________________ _____________________________________________
Phone Date

Rev. 09.16.20

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